The Three Thyroid Myths

TSQ Thyroid and Metabolism Questionnaire - Public

Name*
First Last
Email*
Date*
MM slash DD slash YYYY
This questionnaire helps you determine the function of thyroid hormone in your body. Regardless if you have had a lab test that say your thyroid is normal or that you may be taking prescription thyroid medication, you still may have problems with metabolism that directly relate to how thyroid hormone is functioning in your body.

In front of each question enter the following score:

10 = If this is a noticeable issue or significant problem.

5 = If this is a problem, but not a major issue

2 = If this happens every now and then, but you don’t notice it too much.

0 = If you seldom or never have this issue.
1) Are you cold (cold hands/feet)?*
Please enter a number from 0 to 10.
2) Do you have a swelling in the neck area?*
Please enter a number from 0 to 10.
3) Are you overweight? (10 if over 20 lbs, 5 if 10-19 lbs, 2 if 5-9 lbs)*
Please enter a number from 0 to 10.
4) Can you eat very little and still not lose weight (or you gain weight too easily)?*
Please enter a number from 0 to 10.
5) Are you tired all the time?*
Please enter a number from 0 to 10.
6) Do you wake up with headaches/heavy head that wears off as the day progresses?*
Please enter a number from 0 to 10.
7) Do you always need a lot of sleep, and even then you don’t feel well rested?*
Please enter a number from 0 to 10.
8) If you sit down during the day do you get tired (energy drops when you stop moving)?*
Please enter a number from 0 to 10.
9) Does your energy significantly drop in the afternoon?*
Please enter a number from 0 to 10.
10) Do you rely on caffeine, nicotine, or some other stimulant to keep your energy going?*
Please enter a number from 0 to 10.
11) Women - Are your moods noticeably worse with your menstrual cycle or transition? Men - Do you lack a morning erection (never get one=10, sometimes=5, occasionally=2)*
Please enter a number from 0 to 10.
12) Does stress cause you to feel irritable too easily (short fuse, low tolerance)?*
Please enter a number from 0 to 10.
13) Are you depressed, easily prone to depression, and/or feel less communicative or withdrawn?*
Please enter a number from 0 to 10.
14) Are you prone to depression in the fall or spring?*
Please enter a number from 0 to 10.
15) Does your head feel heavy (and/or your memory/concentration is noticeably declining)?*
Please enter a number from 0 to 10.
16) Is the outside portion of your eyebrows thinning (or gone)?*
Please enter a number from 0 to 10.
17) Do you have dry skin and/or dry hair?*
Please enter a number from 0 to 10.
18) Do you have rough patches of skin on your elbows?*
Please enter a number from 0 to 10.
19) Is your hair falling out (or less body hair than what you would consider “normal” on your head, legs (especially calves), arms, armpits, eyelids, eyebrows and pubic area)?*
Please enter a number from 0 to 10.
20) Are you prone to constipation (including having to strain to eliminate)?*
Please enter a number from 0 to 10.
21) Do you have numbness in your extremities or have carpal tunnel syndrome?*
Please enter a number from 0 to 10.
22) Are you prone to facial fluid retention, especially around the eyes?*
Please enter a number from 0 to 10.
23) Is your voice hoarse or coarse?*
Please enter a number from 0 to 10.
24) Do you get muscle cramps or have general muscle weakness?*
Please enter a number from 0 to 10.
25) Do you have high or low cholesterol? (10 if over 250, 5 if 220-249, 2 if 201-219, 0 if 161-200, 10 if under 140, 5 if 141-160)*
Please enter a number from 0 to 10.
Grand Total*
If your total score is over 100 you have a significant metabolism problem. Most likely, the thyroid hormone is not working in a proper manner and the thyroid issues are causing other health problems.

If your score is in the 50-100 range, you have a noticeable metabolism problem. Most likely, thyroid hormone function in your body is struggling. Steps need to be taken to prevent health issues from magnifying.

If your score is in the 20-49 range, you are showing signs of metabolism wear and tear. The higher your score in this range the greater the need to take preventive steps to keep your health on track.

If your score is under 20 your metabolism is in good condition.
How did you hear about us?*
Which event?
Who referred you?

The following questionnaire is used to determine your current health status, based on your symptoms. The Thyroid/Adrenal Symptoms Questionnaire (TSQ) identifies symptoms that help to determine the underlying causes of illness, and helps us track your progress over time. It focuses specifically on symptoms related to thyroid and/or adrenal dysfunction. Rate each of the following symptoms based upon your personal assessment of your overall current health status.

TSQ Thyroid and Metabolism Questionnaire - Public

Name*
First Last
Email*
Date*
MM slash DD slash YYYY
This questionnaire helps you determine the function of thyroid hormone in your body. Regardless if you have had a lab test that say your thyroid is normal or that you may be taking prescription thyroid medication, you still may have problems with metabolism that directly relate to how thyroid hormone is functioning in your body.

In front of each question enter the following score:

10 = If this is a noticeable issue or significant problem.

5 = If this is a problem, but not a major issue

2 = If this happens every now and then, but you don’t notice it too much.

0 = If you seldom or never have this issue.
1) Are you cold (cold hands/feet)?*
Please enter a number from 0 to 10.
2) Do you have a swelling in the neck area?*
Please enter a number from 0 to 10.
3) Are you overweight? (10 if over 20 lbs, 5 if 10-19 lbs, 2 if 5-9 lbs)*
Please enter a number from 0 to 10.
4) Can you eat very little and still not lose weight (or you gain weight too easily)?*
Please enter a number from 0 to 10.
5) Are you tired all the time?*
Please enter a number from 0 to 10.
6) Do you wake up with headaches/heavy head that wears off as the day progresses?*
Please enter a number from 0 to 10.
7) Do you always need a lot of sleep, and even then you don’t feel well rested?*
Please enter a number from 0 to 10.
8) If you sit down during the day do you get tired (energy drops when you stop moving)?*
Please enter a number from 0 to 10.
9) Does your energy significantly drop in the afternoon?*
Please enter a number from 0 to 10.
10) Do you rely on caffeine, nicotine, or some other stimulant to keep your energy going?*
Please enter a number from 0 to 10.
11) Women - Are your moods noticeably worse with your menstrual cycle or transition? Men - Do you lack a morning erection (never get one=10, sometimes=5, occasionally=2)*
Please enter a number from 0 to 10.
12) Does stress cause you to feel irritable too easily (short fuse, low tolerance)?*
Please enter a number from 0 to 10.
13) Are you depressed, easily prone to depression, and/or feel less communicative or withdrawn?*
Please enter a number from 0 to 10.
14) Are you prone to depression in the fall or spring?*
Please enter a number from 0 to 10.
15) Does your head feel heavy (and/or your memory/concentration is noticeably declining)?*
Please enter a number from 0 to 10.
16) Is the outside portion of your eyebrows thinning (or gone)?*
Please enter a number from 0 to 10.
17) Do you have dry skin and/or dry hair?*
Please enter a number from 0 to 10.
18) Do you have rough patches of skin on your elbows?*
Please enter a number from 0 to 10.
19) Is your hair falling out (or less body hair than what you would consider “normal” on your head, legs (especially calves), arms, armpits, eyelids, eyebrows and pubic area)?*
Please enter a number from 0 to 10.
20) Are you prone to constipation (including having to strain to eliminate)?*
Please enter a number from 0 to 10.
21) Do you have numbness in your extremities or have carpal tunnel syndrome?*
Please enter a number from 0 to 10.
22) Are you prone to facial fluid retention, especially around the eyes?*
Please enter a number from 0 to 10.
23) Is your voice hoarse or coarse?*
Please enter a number from 0 to 10.
24) Do you get muscle cramps or have general muscle weakness?*
Please enter a number from 0 to 10.
25) Do you have high or low cholesterol? (10 if over 250, 5 if 220-249, 2 if 201-219, 0 if 161-200, 10 if under 140, 5 if 141-160)*
Please enter a number from 0 to 10.
Grand Total*
If your total score is over 100 you have a significant metabolism problem. Most likely, the thyroid hormone is not working in a proper manner and the thyroid issues are causing other health problems.

If your score is in the 50-100 range, you have a noticeable metabolism problem. Most likely, thyroid hormone function in your body is struggling. Steps need to be taken to prevent health issues from magnifying.

If your score is in the 20-49 range, you are showing signs of metabolism wear and tear. The higher your score in this range the greater the need to take preventive steps to keep your health on track.

If your score is under 20 your metabolism is in good condition.
How did you hear about us?*
Which event?
Who referred you?

Name*
First Last
Email*
Date*
MM slash DD slash YYYY
This questionnaire helps you determine the function of thyroid hormone in your body. Regardless if you have had a lab test that say your thyroid is normal or that you may be taking prescription thyroid medication, you still may have problems with metabolism that directly relate to how thyroid hormone is functioning in your body.

In front of each question enter the following score:

10 = If this is a noticeable issue or significant problem.

5 = If this is a problem, but not a major issue

2 = If this happens every now and then, but you don’t notice it too much.

0 = If you seldom or never have this issue.
1) Are you cold (cold hands/feet)?*
Please enter a number from 0 to 10.
2) Do you have a swelling in the neck area?*
Please enter a number from 0 to 10.
3) Are you overweight? (10 if over 20 lbs, 5 if 10-19 lbs, 2 if 5-9 lbs)*
Please enter a number from 0 to 10.
4) Can you eat very little and still not lose weight (or you gain weight too easily)?*
Please enter a number from 0 to 10.
5) Are you tired all the time?*
Please enter a number from 0 to 10.
6) Do you wake up with headaches/heavy head that wears off as the day progresses?*
Please enter a number from 0 to 10.
7) Do you always need a lot of sleep, and even then you don’t feel well rested?*
Please enter a number from 0 to 10.
8) If you sit down during the day do you get tired (energy drops when you stop moving)?*
Please enter a number from 0 to 10.
9) Does your energy significantly drop in the afternoon?*
Please enter a number from 0 to 10.
10) Do you rely on caffeine, nicotine, or some other stimulant to keep your energy going?*
Please enter a number from 0 to 10.
11) Women - Are your moods noticeably worse with your menstrual cycle or transition? Men - Do you lack a morning erection (never get one=10, sometimes=5, occasionally=2)*
Please enter a number from 0 to 10.
12) Does stress cause you to feel irritable too easily (short fuse, low tolerance)?*
Please enter a number from 0 to 10.
13) Are you depressed, easily prone to depression, and/or feel less communicative or withdrawn?*
Please enter a number from 0 to 10.
14) Are you prone to depression in the fall or spring?*
Please enter a number from 0 to 10.
15) Does your head feel heavy (and/or your memory/concentration is noticeably declining)?*
Please enter a number from 0 to 10.
16) Is the outside portion of your eyebrows thinning (or gone)?*
Please enter a number from 0 to 10.
17) Do you have dry skin and/or dry hair?*
Please enter a number from 0 to 10.
18) Do you have rough patches of skin on your elbows?*
Please enter a number from 0 to 10.
19) Is your hair falling out (or less body hair than what you would consider “normal” on your head, legs (especially calves), arms, armpits, eyelids, eyebrows and pubic area)?*
Please enter a number from 0 to 10.
20) Are you prone to constipation (including having to strain to eliminate)?*
Please enter a number from 0 to 10.
21) Do you have numbness in your extremities or have carpal tunnel syndrome?*
Please enter a number from 0 to 10.
22) Are you prone to facial fluid retention, especially around the eyes?*
Please enter a number from 0 to 10.
23) Is your voice hoarse or coarse?*
Please enter a number from 0 to 10.
24) Do you get muscle cramps or have general muscle weakness?*
Please enter a number from 0 to 10.
25) Do you have high or low cholesterol? (10 if over 250, 5 if 220-249, 2 if 201-219, 0 if 161-200, 10 if under 140, 5 if 141-160)*
Please enter a number from 0 to 10.
Grand Total*
If your total score is over 100 you have a significant metabolism problem. Most likely, the thyroid hormone is not working in a proper manner and the thyroid issues are causing other health problems.

If your score is in the 50-100 range, you have a noticeable metabolism problem. Most likely, thyroid hormone function in your body is struggling. Steps need to be taken to prevent health issues from magnifying.

If your score is in the 20-49 range, you are showing signs of metabolism wear and tear. The higher your score in this range the greater the need to take preventive steps to keep your health on track.

If your score is under 20 your metabolism is in good condition.
How did you hear about us?*
Which event?
Who referred you?

Thyroid Issues

The Three Thyroid Myths

TSQ Thyroid and Metabolism Questionnaire - Public

TSQ Thyroid and Metabolism Questionnaire - Public

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