Thyroid Risk & Clinical Marker Assessment

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The Insulin Friendly Lifestyle & Rotational Fasting

Sources:
Institute for Functional Medicine
"Clinical Scoring Scales in Thyrology" Kalra, 2016

YYYY

Time

Full Name *

Phone Number *

Pre-Evaluation: Family History & Predisposition Factors Survey *

Yes

My family has a history of thyroid disease

I’ve had a thyroid problem

I have an autoimmune disease

A member of my family has an autoimmune disease

I have had radiation treatment to my head, neck, chest, tonsil area, etc.

I grew up, live, or work near a nuclear plant

Women: I have a history of infertility or miscarriage

I have a one of these digestive issues: Irritable Bowel, Gut Dysbiosis, SIBO, Leaky Gut

None Apply to me

Yes

My family has a history of thyroid disease

I’ve had a thyroid problem

I have an autoimmune disease

A member of my family has an autoimmune disease

I have had radiation treatment to my head, neck, chest, tonsil area, etc.

I grew up, live, or work near a nuclear plant

Women: I have a history of infertility or miscarriage

I have a one of these digestive issues: Irritable Bowel, Gut Dysbiosis, SIBO, Leaky Gut

None Apply to me

Thyroid Risk & Clinical Marker Assessment: Please mark each question as Mild, Moderate, or Severe in the indicated space to the right of each question. *

Mild (1 point)

Moderate (2 pts)

Severe (3 pts)

None

Difficulty remembering things

Can’t think of the right word

Making careless mistakes

Heart palpitations

Tired and lack of energy

Feel unusually cold often

Gained weight recently

Headaches

Aches and pains all over the body

Trouble thinking clearly

Clumsy, bumped into things

Difficulty reading and spelling

Diminished sweating

Dry skin

Cold intolerance

Constipation

Hoarseness

Trouble hearing or hearing changes

Slow movements or reflexes

Coarse skin

Cold skin

Puffiness under the eyes

I feel worse than I did a year ago

Feel the cold more, harder to get warm than before

Appetite is getting worse

Voice has become huskier or weaker over time

I think I am getting fuller in the face

Skin of my arms or legs is getting dry or rough

Hair has become unruly or more difficult to manage

My “normal” body temperature is low (below 98.2°)

Hands and feet are cold to the touch

Low pulse, and/or low blood pressure

Dry and brittle nails that break more easily

Eyes feel gritty, dry, light-sensitive

Diminished sex drive

Mild (1 point)

Moderate (2 pts)

Severe (3 pts)

None

Difficulty remembering things

Can’t think of the right word

Making careless mistakes

Heart palpitations

Tired and lack of energy

Feel unusually cold often

Gained weight recently

Headaches

Aches and pains all over the body

Trouble thinking clearly

Clumsy, bumped into things

Difficulty reading and spelling

Diminished sweating

Dry skin

Cold intolerance

Constipation

Hoarseness

Trouble hearing or hearing changes

Slow movements or reflexes

Coarse skin

Cold skin

Puffiness under the eyes

I feel worse than I did a year ago

Feel the cold more, harder to get warm than before

Appetite is getting worse

Voice has become huskier or weaker over time

I think I am getting fuller in the face

Skin of my arms or legs is getting dry or rough

Hair has become unruly or more difficult to manage

My “normal” body temperature is low (below 98.2°)

Hands and feet are cold to the touch

Low pulse, and/or low blood pressure

Dry and brittle nails that break more easily

Eyes feel gritty, dry, light-sensitive

Diminished sex drive

Important Note: Please indicate below how many "Family & Predisposition Factors" that you had from the first section. The presence of any one or multiple Factors will increase overall risk for thyroid disorders independently. *

I have no factors present

I have 1-2 factors (3 points)

I have 3-4 factors (5 points)

I have 4 or more factors (8 points)

Add up all your responses to get your score using the values for each answer, then mark the appropriate result range below, and continue to the end to interpret results. Scoring: Mild= (1) Moderate = (2) Severe = (3) *

21+ pts.: Advanced Thyroid Dysregulation Clinical Markers as observed in both Autoimmune and Non-Autoimmune Hypothyroid Conditions. You may have noticed your blood tests say your cholesterol and triglycerides increased. Your energy level can vary greatly, headaches are common, and your mood is feeling more like depression. You can’t lose weight and doctors don’t offer you many answers. To start feeling better, more like yourself with vibrant energy, restored desire to do basic things and have the mental clarity to get them done your thyroid function needs to improve. This will require an integrated lifestyle program that includes supplemental thyroid support, metabolic exercise (when you’re ready), stress resilience practices, increased sleep quality, and a specific nutrition plan for, “what” you eat, as well as a a plan for “when” to eat using meal timing and modified fasting. It’s important to find a health care professional with experience in this area and especially with fasting. Your provider must be aware of the risks and contraindications associated with thyroid conditions. Insulin resistance is almost universally accompanying chronic thyroid conditions. A good practitioner can help you see significant thyroid improvements and insulin resistance in about one month, and you could recover completely in three to six months. There’s no more time to waste.

16-20 pts: Moderate Impact & Positive Thyroid Clinical Profile. This means clinical indicators of thyroid risk and potential impairment are present. Early thyroid dysfunction, the most common being “subclinical hypothyroid” or “Mild Thyroid Failure,” is only diagnosed off lab results and usually not identified until advanced problems set in. You may have been “running on fumes” for a while and it has starting to show in your life and quality of life. You know something is not “right.” You are often cold when others are not and may have noticed changes in your hair and nails. Sleep has become challenging; brain fog is common and physical aches are felt more than before. All of this can impact your mood and motivation. You have gained weight or noticed clothes feel tighter, and your usual routine to drop a few pounds isn’t working and might make it worse. You need to make your thyroid and metabolic health a priority, do some research, and work on a plan to restore your healthy thyroid function. Lifestyle modification in your diet, physical activity among others still proves very effective.

10-15 pts.: Evidence of Thyroid Involvement & Potential Compromise Adrenal Compromise. Your thyroid markers are showing signs of mild compromise. Some people at this point report no significant changes in their health or quality of life even with thyroid compromise. Many others report irregular energy levels, trouble concentrating or “brain fog”, or becoming easily irritated. Exercise stamina is decreased slightly, and unusual changes in digestion are noted. It’s not quite as easy to stay on task and you notice your skin more sensitive than it used to be. This is an excellent time to address this thyroid compromise before it progresses.

0-9 points: Healthy Thyroid Function! Your score indicates that your Thyroid response is strong and healthy. I know a score like this doesn’t come as a surprise, or by accident. Your overall health regimen is paying off, congratulations. You wake up easily from a good night’s sleep and maintain a positive outlook and vibrant energy throughout the day. You don’t experience overwhelm and your mental clarity is noticeable. You must enjoy clean eating, regular exercise free of discomfort, and incorporate stress resilience practices regularly. I personally invite you to join our community at the Insulin Friendly Lifestyle & Fasting Rotation to share your success story and help others achieve their own.

Thyroid dysfunction robs quality of life. Thyroid function is part of the hormonal trifecta with Insulin & Cortisol & bully other hormones causing: Pre & Type 2 Diabetes, Metabolic Syndrome, Heart Disease, Obesity, Weight Loss Resistance, Adrenal Fatigue, Autoimmune Conditions, Low T & Estrogen Imbalance, stopping Ketosis & Autophagy, speeds aging & 90% of cancers. Dr. Don's Insulin Friendly Lifestyle & Fasting Rotation Program stops the Trifecta, & promotes healing. I'm inviting you to a FREE 15 min call to discuss your metabolic health & see how I can help. CLICK YES! then use the link to book your call! *

YES! I am booking my FREE Meet & Greet call with Dr. Don https://calendly.com/insulinfriendly/15min

No thank you, I will continue on my own.

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