Diet Plan Questionnaire 

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Diet Plan Questionnaire Form (Please complete this form to the best of your ability)

Under-active Thyroid

Yes
No
Male
Female
Transgender
Day Shift
Night Shift
Yes
No
Yes
No
Yes
No
Yes
No
Carnivore (meat consumer)
Vegetarian
Vegan
Pescatarian
Chicken
Lamb
Beef
Pork
Table Salt
Himalayan Salt / Pink Salt
Sea salt
Not sure
1
2
3
4
5 or more
Yes
No
Yes
No
Cigarettes
Alcohol
E Cigarettes / Vape
Yes
No
Pizza
Fish and chips
Curry
Fried Chicken burger meal
Other
Yes
No
Gym
Walking
Running

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