FORM: Got Hashimoto's? Join the club...

Name*
FirstLast
Email*
Address
Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeCountry
Phone (Home)
Phone (Mobile)*
Date Of Birth*
Occupation*
Referred by*
- Web
- Friend
Height (cm)
Weight (if known)
Blood Type (if known)

When was the last time you took antibiotics and how long for?*
Approximately how many times have you taken antibiotics over the course of your life?*
Have you ever taken steroid drugs such as cortisone?
- Yes
- No
If so what for and approx. how many times?
Did you have any recurrent childhood illnesses & treatment?
eg. Asthma, bronchitis, tonsillitis, urinary tract infections, middle ear infections, eczema, etc
Were you breast fed as a baby?
- Yes
- No
If so for how long?
Please list any major operations / surgery and when they occurred
Please list any major adult illnesses and when they occurred
Do you come into contact with any chemicals at home or at work? If so what type?
Are you aware of any known allergies or possible allergy symptoms including sinus congestion, hay fever, excess mucous production, skin rashes, headaches, bowel disturbances, abdominal bloating fatigue after eating?
Are you aware of any mould or mustiness in your home or work environment?
- Yes
- No
Which room/s is most effected
Do you have any food cravings or aversions? eg salty or sweet foods, coffee, alcohol
- Yes
- No
If so please detail and are they worse at any time of the day or night/month
Do you have any particular eating pattern? Eg: vegetarian, macrobiotic, low fat, diabetic etc
How long have you followed this diet?

Diet Overview
List all the foods and drinks you consumed in the past three days:
Day 1*
Breakfast Lunch Dinner Snacks
Cups of coffee?
Cups of Tea?
Alcoholic beverages? (Units)
1 standard beer or wine = 1 unit
Day 2*
Breakfast Lunch Dinner Snacks
Cups of coffee?
Cups of Tea?
Alcoholic beverages? (Units)
1 standard beer or wine = 1 unit
Day 3*
Breakfast Lunch Dinner Snacks
Cups of coffee?
Cups of Tea?
Alcoholic beverages? (Units)
1 standard beer or wine = 1 unit
How many glasses or litres of water do you drink each day?*
Is it filtered, bottled or tap?*
- Filtered
- Bottled
- Tap
How often do you have a bowel motion?*
Please indicate which of the following is most typical for you:
- a) Stools are usually easy to pass and well formed
- b) Stools are usually difficult to pass and dry
- c) Stools are often loose
- d) Stools are commonly a mix between a) b) c)?
Are your stools ever pale in colour or very dark on a regular basis?*
- Yes
- No

FORM: Got Hashimoto’s? Join the club…