Thyroid Epigenetic Mapping Assessment

Thyroid Epigenetic Mapping Assessment
Please complete this form prior to your thyroid consult with our team.

The form will take 10-20 minutes to complete.

Start by entering the SAME email you used to purchase.

If you have any trouble, feel free to respond to any of the emails we sent...thanks!
Name*
Email*
Sex*

MaleFemale
Age*
Please list the top 3 symptoms/issues your are currently wanting to get help with?
What else have you tried to help improve your thyroid health?
If this is a good fit, how soon are you looking to start getting our help?

ImmediatelyWithin the next few weeksIn the future (other pressing matters to take care of first)
We offer various payment plans and financing options, starting at just a few hundred dollars a month. Which option best suits you at this time?

I'm willing to invest in my health if the program is a good fit.I have limited resources and am not able to invest at this time.

SLEEP
Do you have difficulty sleeping, experience nervousness or hyperactivity? - If so, how often?*

Infrequently/NoOccasionalDaily
Do you snore or have sleep apnea (stop breathing at times or gasp during the night)? - If so, how often?*

Infrequently/NoOccasionalDaily

IMMUNITY
Do you suffer from sinus issues, asthma, or allergies (including rashes, eczema, and hives)? - If so, how often?*

Infrequently/NoOccasionalDaily
Do you get frequent colds and flus?*

Infrequently/NoYes one time a yearYes multiple times a year
Do you have an autoimmune condition (ie MS, Ulcerative Colitis, Crohn's Disease, Rheumatoid Arthritis, Meniere's Disease, and Raynaud's Phenomenon)?*

YesNo

LUNGS
Do you experience shortness of breath?*

YesNo
Do you cough easily or have a history of asthma?*

Infrequently/NoOccasionalDaily