Your State of Hormones & Thyroid Health Report

It is important to find the driving factors for feeling unwell. Hormones are chemical messengers of the body. When there are hormonal imbalances we can experience a range of symptoms that can be annoying to debilitating. this questionnaire will give you insight into what systems are being challenged or compromised and where you might need some assistance in bringing back balance to your life.

Please select any of the symptoms that you are experiencing.

You will receive a copy of your report as will the clinic providing the questionnaire, so you may discuss your health concerns with a professional.

Your information is confidential at all times.


Note: All fields marked with a red asterix * are required fields.
Your Details
Name *
Age *
Email *
Phone (if wanting to be contacted by the Clinic)
Diagnosed Medical Conditions (if applicable)
Do you currently take medication for any diagnosed medical conditions?
What is your first concern when it comes to your health? *
  • Hormone health

    These questions relate to your hormonal health

  • Thyroid Health

    Please select all the symptoms that you experience regularly or have experienced consistently in the past.

  • Adrenal health

    Please select any symptom that you experience or have done in the last 5 years

  • Toxic load

    Please select all the symptoms you experience regularly or have experienced consistently in the past.

  • Gut health

    please select all the symptoms that you experience regularly

  • Liver and elimination

    please select all symptoms that you experience regularly

  • Inflammation

    please select all symptoms you experience regularly

  • Microbiome

    please select all the symptoms that you experience

  • Stress

    please select any symptom that you are experiencing

  • Immune system

    please select any of the symptoms you experience.


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