General Contact Information
Products Used and History
Acidosis and Chemical / Heavy Metal Toxicity Self Evaluation / Assessment
These items are presented as the questionnaire’s self-evaluation prompts. Checking a symptom does not establish a diagnosis.
Nutritional Self / Evaluation
Thyroid Symptom Survey
Symptom rating from the source questionnaire: 0 = I do not have this · 1 = Mild · 2 = Moderate · 3 = Severe.
0–9: Unlikely you are hypo/hyperthyroid · 10–19: Mild · 20–29: Moderate · 30+: Severe.
This scoring language is reproduced from the uploaded questionnaire. It should not be treated as a standalone medical diagnosis.
Acknowledgement and Disclaimer
The source questionnaire states that the information sought is nutritional in nature and is not a medical diagnosis, treatment, disease prevention, or health assessment. It also states that materials are educational/informational, are not medical, psychological, or nutrition therapy advice, and that users should consult their own medical practitioner before modifying a regular medical regimen.
For readability, this Magic HTML summarizes the acknowledgement here. The original wording remains preserved in the uploaded questionnaire.
The form is a starting point for conversation.
A completed questionnaire can help organize what to discuss next, but it should remain one input among your own experience, current medical care, medication history, nutritional goals, and professional guidance.