Center for Hormonal Healing

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Thyroid Evaluation
Progesterone Evaluation
Estrogen Evaluation
Testosterone Evaluation
Adrenal Function Evaluation
Why are my hormone levels low?

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Do you have low thyroid function (hypothyroidism)?

Thyroid Evaluation

Below are a list of symptoms and other factors most commonly found in people suffering from low thyroid, or hypothyroidism. Read each question carefully and check the box if it applies to you. The form will automatically calculate your score.

	I have fatigue.	Evaluation Score < 12 — It is unlikely that you have low thyroid. Please continue with your full evaluation. > 12 — Low thyroid function is likely. We recommend that you schedule a consultation.
	I have elevated cholesterol.
	I have difficulty losing weight.
	I have cold hands and feet.
	I am sensitive to the cold.
	I have difficulty thinking.
	I find it hard to concentrate.
	I frequently experience "brain fog."
	I have poor short term memory.
	I commonly have depressed moods.
	I am experiencing hair loss.
	I have less than one bowel movement a day.
	I have dry skin.

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William Hedden M.D. | 111 Village Street, Birmingham, AL 35242 | Phone: (205) 980-1744 | Fax: (205) 980-1334
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