Thyroid-survey-Miceli

This could be the first step to a healthier you. Complete the below questionnaire to find out if we can help you.

Was your thyroid removed?	*	Yes No
Are you on thyroid medication?	*	Yes No
Are you constantly tired?	*	Yes No
Do you have trouble falling or staying asleep?	*	Yes No
Do you experience hair loss?	*	Yes No
Is you skin extremely dry?	*	Yes No
Do you have severe weight gain?	*	Yes No
Do you suffer from depression?	*	Yes No
Do you have mood swings?	*	Yes No
Do you suffer from anxiety?	*	Yes No
First Name	*
Last Name	*
Email Address
Phone Number
Address	*
City	*
State	*
Zip / Postal	*