Claim Your Exclusive Opportunity:
Complete Your Health History and Schedule a Hypothyroid Free Consultation Today! Application - Intake
Date
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Month
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Day
Year
Date
Name
*
First Name
Last Name
City
*
Country
State
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Zip Code
*
Phone
*
Email
*
example@example.com
Date of Birth
*
/
Month
/
Day
Year
Date
Weight
Marital Status?
*
Please Select
Married
Divorced
Widowed
Other
Do you have children? Ages?
How Did You Hear About Us?
*
Employer/Occupation
*
List Your Main Problems
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In spite of the fact that you are not a doctor, you are in fact the person who knows more about your condition than anyone else. In your opinion, what do you think the real problem is?
*
Have you been diagnosed with hypothyroid?
Please Select
Yes
No
Check the diagnosis that you have been given
*
Hashimotos
Hypothyroid
Hyperthyroid
Grave's Disease
None of the above
List your current symptoms
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What relieves your symptoms or causes them to return?
If your symptoms include pain, describe the quality of pain.Please select all that apply:
Dull
Sharp
Shooting
Radiating
Have you received Prescription/Drug Therapy?
Have you received Nutritional Supplementation?
Have you received Alternative/Holistic Therapy?
What are you hoping happens today as a result of your consultation?
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If you cannot find a solution to your problem what do you think will happen?
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What are the top three things your condition has caused you to miss most?
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Which best describes the severity of your problem?
Minimal (annoying but causing no limitation)
Slight (tolerable but causing a little limitation)
Moderate (sometimes tolerable but definitely causing limitation)
Severe (causing significant limitation)
Extreme (causing near constant limitation)
List your health goals in order of importance.
*
What is your motivation level to achieve these goals? (10 = highest motivation level) Please select one:
Please Select
1
2
3
4
5
6
7
8
9
10
Due to your condition, have you lost time from work?
Please Select
YES
NO
How often are you aware of your main problem?
Occasionally (25% of the time)
Intermittently (50% )of the time
Frequently (75% of the time)
Constantly (100% of the time)
Due to your condition, have you lost time from family?
YES
NO
Due to your condition, have you lost time from leisure activities?
YES
NO
Medications
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Supplements
Surgeries/Hospitalizations
Trauma (physical and/or emotional)
Past/Recent Illnesses
Family Medical History
Do you consume alcohol?
YES
NO
Do you use tobacco products? (cigarettes, chewing tobacco, dip, vape, etc)
Please Select
YES
NO
Do you consume caffeine?
Please Select
YES
NO
Select if you have or have ever had any of the following conditions:
Acne
Addictions (alcohol, drugs)
Anemia
Anorexia
Anxiety or nervousness
Arthritis (Rheumatoid or Osteo)
Bladder infections (Cystitis)
Bloating, gas or indigestion
Blood sugar problems
Bronchitis
Cancer
Colds or flu (frequent)
Cold sores
Chronic fatigue
Constipation
Dandruff
Depression
Diabetes I (insulin dependent)
Diabetes II (adult onset)
Diarrhea
Emotional problems (instability or sensitivity)
Emphysema
Fainting
Gall bladder problems
Gout
Hair loss or poor hair growth
Headaches
Heart disease or problems
Heartburn
Herpes simplex I or type II
High blood pressure
High cholesterol
HIV
Hot flashes
Hypoglycemia
Insomnia
Intestinal problems
Kidney stones
Liver problems
Loose stools
Memory loss or confusion
Nails, poor growth
Panic attacks
Pregnant or nursing mother
Respiratory problems
Ringing in ears
Seizures
Severe mood swings
Skin conditions
Stroke
Suicidal tendencies
Thyroid condition
Ulcer
Yeast infections
Multiple chemical sensitivity
Other
List all known allergies (drugs, food, or environmental)
Parent/Guardian Name (if client is under 18)
*
Signature
*
Appointment
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