Hormones/Thyroid Survey

When your hormone levels go out of normal ranges, you can experience a variety of seemingly unrelated symptoms from weight gain to hair loss to mood swings. If hormone imbalances are causing your symptoms, our Living Well Program can help you get back to normal. Take this short survey to see if you’d be a good candidate!

Please fill out this short survey including your contact information so that we can contact you further if needed. Your information will remain safe and confidential.

Rate each of the following based on your health in the last 90 days:

  • 0 = Rarely or never experience the symptom
  • 1 = Occasionally experience but effect is not severe
  • 2 = Occasionally experience but effect is severe
  • 3 = Frequently experience and effect is not severe
  • 4 = Frequently experience and effect is severe
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  • 01234