1. What is your body weight?

• Normal, within a few pounds
• 5 to 20 pounds overweight
• More than 20 pounds overweight
• 3 to 10 pounds underweight
• More than 10 pounds underweight

2. Are you fatigued?

• Yes, I’m always tired
• Occasionally feel fatigued
• Not often

3. Do you feel cold (prone to cold hands/feet) or uncomfortably warm at times?

• I always feel cold
• Hands or feet are often cold
• I feel too warm
• I do not feel too warm or too cold

4. Do you have trouble focusing or remembering names?

• Yes, I frequently lose everyday items like keys and have memory problems
• I sometimes have a problem with this
• No problem

5. Do you experience bloating or other digestive issues?

• Yes, I frequently experience bloating or other digestive issues
• Yes, I sometimes have digestive problems
• No, I do not have digestive issues

6. Have you noticed your hair or eyebrows thinning?

• Noticeable loss or thinning
• Thinning to some extent
• No hair problems

7. Do you have trouble sleeping?

• Yes, I always have trouble falling asleep or staying asleep
• Yes, I sometimes have problems sleeping
• No sleeping problem