Hashimotos &Hypothyroid Wellness Assessment
WHY AM I ASKING YOU TO FILL OUT THIS FORM? Hi, my name is Sarah and I was diagnosed with Hashimotos Disease in 2007. I had EVERY symptom in the book and EVERY single doctor gave me GENERIC advice on how to reverse my symptoms. I ask you to PLEASE fill out this form so I can put together a plan WITH you, FOR you, that isn't generic and will help you reverse your symptoms in a NON overwhelming way. If your questions are not about Hashimotos or Hypothyroidism, please email me at SarahRuth@HappyHashiMomma.com.
Name
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First Name
Last Name
Email
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example@example.com
Where did you find me?
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Instagram
Facebook
Pinterest
TikTok
Your Website
YOUR social media handle or URL (so I can reach out to you to let you know your assessment is in your inbox)
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Please fill this out so that way I have a second way to contact you. Most of my emails will go to spam. I will typically text message or DM you to let you know to look for my response.
Where do you live? (City/State/Country)
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City, State, Country
Have you been diagnosed with Hashimotos, Hypothyroidism, Both, or Something?
Hashimotos
Hypothyroidism
Not Formally Diagnosed
Other
If you answered 'Other', please describe.
When were you diagnosed? If not diagnosed, put n/a
If you are on any medication, please list.
What are your current symptoms? Please check all that apply
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Weight gain
Weight Loss
Fatigue
Gas or Bloating
Brain Fog
Mood Swings, Anxiety, and/or Depression
Fertility Issues
Hair, Skin, or Nail Issues
Hives
Inflammation - joint, body, etc
Other
Do you know your root cause?
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Yes
No
Unsure
If yes, please list.
Are you prone to chronic sickness or infections (aka do you get sick or infections often)?
Yes
No
Don't know
Are you currently following a specific diet or nutrition protocol? Please describe. If you know your caloric intake and macros, please provide those as well.
In the last 7 days, how closely have you followed that plan?
0-25%
26-50%
51-75%
76-100%
What’s your biggest nutrition struggle right now? (Planning, cravings, eating out, family resistance, not knowing what to eat, etc.)
Have you had any testing done in the last year? (Yes / No) If yes, please list what kind and any key results you know.
Have you reviewed these results with a functional/holistic provider before? If yes, what did they say? If no, what questions do you still have?
On a scale of 1–10, how committed are you to making changes in your habits to heal?
What changes are you already making to support your healing?
What has stopped you from reaching your health goals so far? (Select all that apply)
Lack of clear plan
Not knowing what actually works my Hashimoto’s
Busy lifestyle/time constraints
Conflicting information online
Lack of accountability/support
Fear of failing again
Other
Why now? What made you reach out today instead of 6 months ago?
What are your top 3 health goals for the next 6–12 months?
If you woke up 6 months from now feeling amazing, what would be different in your body and life?
How would that impact your day-to-day life and relationships?
Before you go -
Often time my emails will go to spam. Because I take the time to personally respond to you, I want to make sure it lands in your inbox. PLEASE add 'sarahruth@happyhashimomma.com' to your contacts or simply shoot me an email to let me know you've submitted your assessment!
Please verify that you are human
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Submit
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