Name *

First Name

Last Name

Do you feel you are constantly racing from one task to the next? *

Yes

No

Do you feel 'wired yet tired'? *

Yes

No

Do you struggle to calm down before bed time or get a second wind in the evening that keeps you up late? *

Yes

No

Do you have difficulty falling asleep or suffer from disrupted sleep? *

Yes

No

Do you get a feeling of anxiety or nervousness and cannot stop worrying about things beyond your control? *

Yes

No

Are you quick to feel anger or rage? *

Yes

No

Do you suffer from sugar cravings, often needing some after each meal? *

Yes

No

Have you noticed an increase in your abdominal circumference? *

Yes

No

Are your menstrual cycles irregular? *

Yes

No

Is your fertility decreased? *

Yes

No

Do you suffer fatigue or burnout? *

Yes

No

Do you notice a loss of stamina - especially between 2pm and 5pm where you might experience a 'dip'? *

Yes

No

Have you noticed that you have an atypical addiction to negative points of view? *

Yes

No

Do you cry for no real reason? *

Yes

No

Do you feel stressed most of the time? *

Yes

No

Do you suffer from insomnia or have difficulty staying asleep for more than a few hours? *

Yes

No

Is your blood pressure low? *

Yes

No

Do you experience postural hypertension - dizziness when standing up? *

Yes

No

Do you have difficulty fighting infection or seem to take a long time recovering from illness? *

Yes

No

Do you have asthma, bronchitis or chronic cough *

Yes

No

Do you have low or unstable blood sugar? *

Yes

No

Have you experienced salt cravings? *

Yes

No

Do you notice excess sweating? *

Yes

No

Do you suffer from nausea, vomiting or loose stools? *

Yes

No

Have you noticed muscle weakness around the knees or just general muscle or joint pain? *

Yes

No

Do you suffer from agitation or severe PMS? *

Yes

No

Do you experience headaches in line with your cycle? *

Yes

No

Do you have painful or swollen breasts? *

Yes

No

Are your menstrual cycles irregular? *

Yes

No

Are your periods heavy or painful? *

Yes

No

Do you experience bloating, especially around your ankles and tummy? *

Yes

No

Do you have ovarian cysts or polyps? *

Yes

No

Is your sleep easily disrupted? *

Yes

No

Are your legs constantly restless and itchy? *

Yes

No

Have you noticed yourself being increasingly clumsy or having poor coordination? *

Yes

No

Do you think you might be infertile or subfertile? *

Yes

No

Do you have a history of miscarriage? *

Yes

No

Do you suffer bloating, puffiness or water retention? *

Yes

No

Have you noticed rapid weight gain on your hips and bottom? *

Yes

No

Has your bra cup size increased? *

Yes

No

Do you have fibroids? *

Yes

No

Are you suffering from endometriosis or painful periods? *

Yes

No

Do you have mood swings, PMS or depression? *

Yes

No

Are you weeping over the most minor things? *

Yes

No

Are you getting migraines and other headaches? *

Yes

No

Are you having difficulty sleeping or suffering insomnia? *

Yes

No

Do you get 'brain fog'? *

Yes

No

Do you get a red flush on your face? *

Yes

No

Do you have gallbladder problems or experience stomach cramps after eating a high fat meal? *

Yes

No

Is your memory poor? *

Yes

No

Are you feeling 'emotionally fragile'? *

Yes

No

Do you suffer with depression, anxiety and lethargy? *

Yes

No

Are you noticing more wrinkles? *

Yes

No

Are you suffering night sweats and/or hot flushes? *

Yes

No

Do you have trouble sleeping or find yourself waking in the night? *

Yes

No

Is your bladder a bit leaky or overactive? *

Yes

No

Do you ever get bladder infections? *

Yes

No

Are your breasts lessening in volume or getting a but droopier? *

Yes

No

Do you get sun damage on your chest, face and shoulders? *

Yes

No

Do your joints ache? *

Yes

No

Do you get minor, but unexplained injuries to your wrists, shoulders. lower back and knees? *

Yes

No

Have you lost your interest in exercise? *

Yes

No

Have you experienced vaginal dryness, irritation or loss of feeling? *

Yes

No

Is your libido low? *

Yes

No

Do you have hair on your face? *

Yes

No

Do you have acne? *

Yes

No

Do you have greasy skin and hair? *

Yes

No

Do you have discoloured armpits? *

Yes

No

Do you have skin tags on your neck and upper torso? *

Yes

No

Do you have hyper or hypo glycaemia? *

Yes

No

Are you reactive, irritable, do you have excessively aggressive authoritarian episodes? *

Yes

No

Do you suffer depression/anxiety? *

Yes

No

Are your menstrual cycles more than every 35 days? *

Yes

No

Are you infertile? *

Yes

No

Do you have Polycystic Ovary Syndrome? *

Yes

No

Have you been prescribed Thyroxin? *

Yes

No

Do you have hair loss, including eyebrows? *

Yes

No

Do you have dry skin? *

Yes

No

Do you have dry, straw-like hair? *

Yes

No

Do you have fluid retention and swollen ankles? *

Yes

No

Do you have thin, brittle finger nails? *

Yes

No

Do you have additional pounds that seem impossible to shift? *

Yes

No

Do you have a high cholesterol count? *

Yes

No

Do you have bowel movements less than once a day? *

Yes

No

Do you have recurrent headaches? *

Yes

No

Do you have decreased sweating? *

Yes

No

Do you have muscle and joint aches? *

Yes

No

Do you experience tingling in your hands and feet? *

Yes

No

Do you have cold hands and feet and/or general sensitivity to cold? *

Yes

No

Do you experience fatigue in the morning? *

Yes

No

Do you have sluggish reflexes and diminished reaction time? *

Yes

No

Do you have low sex drive? *

Yes

No

Do you experience depression or moodiness?

Yes

No

Have you been prescribed antidepressants? *

Yes

No

Do you have heavy periods?

Yes

No

Do you have a history of infertility and/or miscarriage? *

Yes

No

Do you have an enlarged thyroid? *

Yes

No

Do you have a family history of thyroid problems? *

Yes

No