Thyroid Gut Gycaemia Gluten

GUT THYROID BLOOD SUGAR CELIAC

First Name

Last Name

Patient Gender

Patient Age

Symptom Severity / Frequency
0 = Never
1 = Mild or Infrequent Symptoms (twice per week or less)
2 = Moderate or Frequent Symptoms (3-6 times a week)
3 = Severe or Daily Symptoms

Tip
If your response is Never, you do not need to click and you can skip that question. If however, you do change your mind for example from Mild (1) to Never (0) you will need to click.

Malabsorption & Dysbiosis Screening

Do you experience any of the following symptoms related to poor digestion,malabsorption, or an imbalance of gut bacteria?

Frequent bloating, gas, or abdominal distension after meals

Mild

Moderate

Severe

Never

Abdominal cramping or discomfort that improves after passing stool/gas

Mild

Moderate

Severe

Never

Loose stools, diarrhea, or urgency more than 3 times per week

Mild

Moderate

Severe

Never

Constipation, infrequent bowel movements, or incomplete evacuation

Mild

Moderate

Severe

Never

Alternating constipation and diarrhea

Mild

Moderate

Severe

Never

Stools that are pale, greasy, float, or difficult to flush

Mild

Moderate

Severe

Never

Unformed, mushy, or irregular stool consistency

Mild

Moderate

Severe

Never

Persistent foul - smelling stools or gas

Mild

Moderate

Severe

Never

Excessive burping or reflux symptoms after eating

Mild

Moderate

Severe

Never

Fatigue, brain fog, or low energy after meals

Mild

Moderate

Severe

Never

Unexplained weight loss or difficulty maintaining weight

Mild

Moderate

Severe

Never

Signs of nutrient deficiency (brittle nails, thinning hair, mouth ulcers, cracked lips)

Mild

Moderate

Severe

Never

History of frequent antibiotic use or recurrent infections

Mild

Moderate

Severe

Never

Strong cravings for sugar, bread, or refined carbohydrates

Mild

Moderate

Severe

Never

Symptoms improve with probiotics, digestive enzymes, or elimination diets

Mild

Moderate

Severe

Never

Undigested food particles visible in stool

Mild

Moderate

Severe

Never

Feeling excessively full or heavy for hours after even a small meal

Mild

Moderate

Severe

Never

Frequent nausea or queasiness not explained by other conditions

Mild

Moderate

Severe

Never

Strong abdominal gurgling or rumbling (borborygmi), especially after meals

Mild

Moderate

Severe

Never

Certain foods (e.g., dairy, gluten, fatty meals) consistently trigger bloating, discomfort, or stool changes

Mild

Moderate

Severe

Never

HYPOTHYROID

Do you experience any of the following symptoms associated with anunderactive thyroid?

Tired, sluggish

Mild

Moderate

Severe

Never

Feel cold - hands, feet, all over

Mild

Moderate

Severe

Never

Tight sensations in neck

Mild

Moderate

Severe

Never

Difficult, infrequent bowel movements

Mild

Moderate

Severe

Never

Dryness, discoloration of skin, hair

Mild

Moderate

Severe

Never

Thick, brittle nails

Mild

Moderate

Severe

Never

Puffy face, hands, and feet

Mild

Moderate

Severe

Never

Swollen upper eyelids

Mild

Moderate

Severe

Never

Eyeballs move involuntarily

Mild

Moderate

Severe

Never

Muscles weak, cramp and/or tremble

Mild

Moderate

Severe

Never

Slow mental processes, forgetfulness

Mild

Moderate

Severe

Never

Slow heart beats

Mild

Moderate

Severe

Never

Abdominal swelling

Mild

Moderate

Severe

Never

Unsteady gait, movements

Mild

Moderate

Severe

Never

Lack of interest in sex

Mild

Moderate

Severe

Never

Gain weight easily

Mild

Moderate

Severe

Never

Swelling of the neck

Yes

Outer third of eyebrow thins

Yes

Thinning hair on scalp, face, and genitals

Yes

Loss of appetite

Yes

Premenstrual tension

Yes

Infertility

Yes

Excessive menstrual bleeding

Yes

Absence of periods

Yes

HYPERTHYROID

Do you experience any of the following symptoms associated with anoveractivethyroid?

Nervousness, anxiety, irritability

Mild

Moderate

Severe

Never

Rapid or irregular heartbeat

Mild

Moderate

Severe

Never

Excessive sweating, heat intolerance

Mild

Moderate

Severe

Never

Unexplained weight loss

Mild

Moderate

Severe

Never

Increased appetite

Mild

Moderate

Severe

Never

Frequent bowel movements, diarrhea

Mild

Moderate

Severe

Never

Shaky hands (tremors)

Mild

Moderate

Severe

Never

Bulging eyes (exophthalmos)

Mild

Moderate

Severe

Never

Swollen or red eyelids

Mild

Moderate

Severe

Never

Insomnia, trouble sleeping

Mild

Moderate

Severe

Never

Muscle weakness, especially in thighs

Mild

Moderate

Severe

Never

Increased thirst

Mild

Moderate

Severe

Never

Shortness of breath

Mild

Moderate

Severe

Never

Increased frequency of urination

Mild

Moderate

Severe

Never

Light or infrequent menstrual periods

Yes

Thinning hair or hair loss

Yes

Enlarged thyroid gland (goiter)

Yes

Difficulty concentrating (brain fog)

Mild

Moderate

Severe

Never

Feeling restless or over - energetic

Mild

Moderate

Severe

Never

Increased sensitivity to light

Mild

Moderate

Severe

Never

Loose or thinning skin

Mild

Moderate

Severe

Never

Brittle nails

Mild

Moderate

Severe

Never

HYPOGLYCAEMIA

Do you experience any of the following symptoms related to low blood sugarlevels?

Sudden anxiety associated with hunger

Mild

Moderate

Severe

Never

Tingling sensation in hands

Mild

Moderate

Severe

Never

Palpitations

Mild

Moderate

Severe

Never

Feel shaky, jittery, tremors

Mild

Moderate

Severe

Never

Weakness

Mild

Moderate

Severe

Never

Profuse perspiration, clammy skin

Mild

Moderate

Severe

Never

Nightmares

Mild

Moderate

Severe

Never

Awake from sleep restless

Mild

Moderate

Severe

Never

Agitated, easily upset

Mild

Moderate

Severe

Never

Poor memory, forgetful

Mild

Moderate

Severe

Never

Confused, disoriented

Mild

Moderate

Severe

Never

Dizziness, feel faint

Mild

Moderate

Severe

Never

Feels cold, numb

Mild

Moderate

Severe

Never

Mild headache

Mild

Moderate

Severe

Never

Blurred vision

Mild

Moderate

Severe

Never

Lack of coordination

Mild

Moderate

Severe

Never

HYPERGLYCAEMIA

Do you experience any of the following symptoms related to highblood sugarlevels?

Excessive, frequent urination

Mild

Moderate

Severe

Never

Increased thirst and appetite

Mild

Moderate

Severe

Never

Blurred vision, failing eyesight

Mild

Moderate

Severe

Never

Fatigue, drowsiness

Mild

Moderate

Severe

Never

Crave sweets, but eating sweets does not relieve craving

Mild

Moderate

Severe

Never

Feel hungry for air (can ’ t get enough)

Mild

Moderate

Severe

Never

Breath smells sweet

Mild

Moderate

Severe

Never

Depressed

Mild

Moderate

Severe

Never

Tingling, numbness, prickling sensation in extremities

Mild

Moderate

Severe

Never

Profuse sweating

Mild

Moderate

Severe

Never

Dribble after voiding

Mild

Moderate

Severe

Never

Impotency

Mild

Moderate

Severe

Never

Dizziness when standing from sitting position

Mild

Moderate

Severe

Never

Slurred speech

Mild

Moderate

Severe

Never

Unintentional weight loss

Yes

Recurring persistent infection (bladder, skin, or gums

Yes

Boils and leg sores

Yes

Very slow wound healing

Yes

Excessive weight gain

Yes

Celiac Disease & Gluten Sensitivity Screening

Do you experience any of the following symptoms or conditions that mayindicate gluten sensitivity or celiac disease?

Do you have an immediate family member (parent, sibling, or child) diagnosed with celiac disease?

Mild

Moderate

Severe

Never

Are you currently following a strict gluten - free diet (avoiding all foods containing wheat, rye, or barley, such as bread, pasta, and baked goods)?

Mild

Moderate

Severe

Never

Do you frequently experience abdominal pain, bloating, diarrhea, or constipation after eating foods like bread, pasta, cereals, or baked goods?

Mild

Moderate

Severe

Never

Have you noticed symptoms such as headache s, fatigue, joint pain, or skin rashes that seem to improve when avoiding foods like pizza, pastries, crackers, or pasta?

Mild

Moderate

Severe

Never

Have you been diagnosed with any autoimmune disorders, such as type 1 diabetes, thyroid disease, or rheumatoid arthritis?

Mild

Moderate

Severe

Never

Do you notice worsening stomach pain, nausea, or digestive discomfort after consuming common gluten - containing foods such as sandwiches, pasta dishes, or cereals?

Mild

Moderate

Severe

Never

Do you experience frequent headaches, brain fog, dizziness, or difficulty concentrating that worsens after eating foods containing wheat, barley, or rye?

Mild

Moderate

Severe

Never

Have you been diagnosed with anemia, low iron, vitamin B12 deficiency, or osteoporosis without a clear cause?

Mild

Moderate

Severe

Never

Do you have an unexplained itchy, blistering skin rash (such as dermatitis herpetiformis) or other autoimmune conditions?

Mild

Moderate

Severe

Never

Have you or your child experienced unexplained weight loss, failure to thrive, or delayed growth despite eating a normal diet?

Mild

Moderate

Severe

Never