The SIBO/Thyroid Assessment Tool

Thyroid/SIBO Assessment Tool

Full Name

Email Address

Age

Date

SECTION 1 – SIBO SCREEN

I have been diagnosed with SIBO

Lactulose breath test has never normalized

I continue to have SIBO symptoms despite treatment

Diarrhea persists

Constipation persists

Alternating diarrhea and constipation persist

Abdominal discomfort persists

Bloating persists

Frank abdominal pain persists

Excessive flatulence persists

Belching persists

Food sensitivity/intolerance persists

I have no symptoms as long as I eat few foods

I have no symptoms as long as I continue anti-microbial treatment

I have no symptoms as long as I continue laxatives, prokinetics, or other agents promoting motility

SECTION 2 – “BIG TICKET” THYROID TENDANCIES

Low energy

Low temperature

Low mood - depression

Low immunity (get sick often or easily)

SECTION 3 – OTHER SIGNS AND SYMPTOMS ASSOCIATED WITH HYPOTHYROIDISM

Slow movements, slow speech, slow reaction time

Weakness

“Brain fog”

Weight gain/difficulty losing weight

Muscle aches

Headaches

Dry, coase skin

Nail problems

Hair thinning

Hair loss

Swelling

Edema

Gum problems

Visual changes

SECTION 4 – MEDICAL CONDITIONS ASSOCIATED WITH DYSTHYROIDISM

Goiter

Swallowing problems

Thyroid nodules

History of autoimmune disease

Family history of dysthyroidism or autoimmune disease

High cholesterol or dyslipidemia

Blood pressure problems

Menstrual cycle problems

Infertility

Menopausal problems

SECTION 5 – MEDICAL CONDITIONS ASSOCIATED WITH HYPERTHYROIDISM

Urgency to stool

Loose stool or frank diarrhea

Excessive perspiration

Always “hot”

Exopthalmos (proptosis)

Heart palpitations

Fast pulse

Agitation or hyperactivity

Family history of dysthyroidism or

Family history of autoimmune disease

*INTERPREATIVE NOTES 1. This tool should not be a replacement for appropriate assessment and diagnosis by a medical professional 2. SECTION 1 can help you understand if SIBO is an ongoing problem, despite treatment 3. SECTIONS 2-5 can help you understand if the thyroid may be one of the underlying causes contributing to of SIBO 4. If the tool points you to a perpetuation of SIBO as well as potential dysthyroidism, you are advised to get further evaluation

DISCLAIMER:

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