Questionnaires

 

 
 
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Digestive Health Questionnaire

This questionnaire will help us discover where your digestive system is having difficulties. This is simply a screening tool and does not constitute an exact diagnosis of your problem. However, it can point us in the right direction in determining where the highest priorities lie in your healing process.

Name *
Name
Stomach
Choose the number that best describes the intensity of your symptoms. If you do not know the answer to a question, leave it blank.
Burping
Fullness
Bloating
Poor Appetite
Stomach upsets easily
History of constipation
Known food allergies
Known Iron-deficiency anemia
Nausea after taking supplements
Small intestine and/or pancreas
Choose the number that best describes the intensity of your symptoms. If you do not know the answer to a question, leave it blank.
Abdominal Cramps
Indigestion one to three hours after eating
Fatique after eating
Lower bowel gas
Alternating contstipation and diarrhea
Diarrhea
Roughage and fiber cause constipation
Mucus in stools
Stool poorly formed
Shiny stool
Three or more large bowel movements daily
Dry, flaky skin and/or dry, brittle hair
Pain in left side under rib cage or chronic stomach pain
Acne
Food allergies
Difficult gaining weight
Foul-smelling stool
Gallstones/history of gallbladder disease
Undigested food in stool
Nausea
Acid reflux/heartburn
Connective tissue disease: lupus, rheumatoid, Sjorens
Alcoholism, diabetes, osteoporosis
Gastric Reflux ("Heartburn")
Choose the number that best describes the intensity of your symptoms. If you do not know the answer to a question, leave it blank.
Sour taste in mouth
Regurgitate undigested food into mouth
Frequent nocturnal coughing
Burning sensation from citrus on way to stomach
Heartburn
Burping
Difficulty swallowing solids or liquids
Ulcers or too much stomach acid in the wrong place
Choose the number that best describes the intensity of your symptoms. If you do not know the answer to a question, leave it blank.
Stomach pains
Stomach pains before or after meals
Dependency on antacids for heartburn/acid reflux
Chronic abdominal pain
Butterly sensations in stomach
Burping or bloating
Stomach pain when emotionally upset
Sudden, acute indigestion
Relief of symptoms by carbonated drinks
Relief of stomach pain by drinking cream or milk
History or family history of ulcer or gastritis
Current ulcer
Black stool when not taking iron supplements
Use or previous use of pain medications: aspririn, ibuprofen, etc.
Liver & Gallbladder
Choose the number that best describes the intensity of your symptoms. If you do not know the answer to a question, leave it blank.
Intolerance to greasy foods
Headaches after eating
Light-colored stool
Foul-smelling stool
Less than one bowel movement daily
Constipation
Hard stool
Sour taste in mouth
Gray-colored skin
Yellow in whites of eyes
Bad breath
Body odor
Fatique and sleepiness after eating
Pain in right side under rib cage
Pain when passing stool
Water retention
Painful big toe
Pain radiates along outside of leg
Dry skin or hair
Red blood in stool
0 = No , 1 = more than two years ago, 2 = current , 3 = chronic
Have had jaundice or hepatitis
0 = No , 1 = more than two years ago, 2 = current , 3 = chronic
High cholesterol and low HDL cholesterol
0 = No , 1 = Unknown , 2 = Yes
Cholesterol level above 200
0 = No , 1 = Unknown , 2 = Yes
Triglyceride level about 115
0 = No , 1 = Unknown , 2 = Yes
Small Intestinal Bacterial Overgrowth (SIBO)
Choose the number that best describes the intensity of your symptoms. If you do not know the answer to a question, leave it blank.
Excessive gas/flatulence
Abdominal bloating and distension, especially with sugar, fiber and carbohydrates
Diarrhea
Abdominal pain
Irritable bowel syndrome
Fibromyalgia
Restless leg syndrome
Intlerance to probiotic supplements
Are taking antacids or proton pump inhibitors for heartburn/GERD
Intestinal Permeability/leaky gut syndrome dysbiosis
Choose the number that best describes the intensity of your symptoms. If you do not know the answer to a question, leave it blank.
Constipation and/or diarrhea
Abdominal pain or bloating
Mucus or blood in stool
Joint pain or swilling, or arthritis
Chronic or frequent fatique or tiredness
Food allergy or food sensitivities or intolerance
Sinus or nasal congestion
Chronic or frequent inflammations
Eczema, skin rashes or hives
Asthma, hay fever, or airborne allergies
Confusion, poor memory or mood swings
Use of nonsteroidal anti-inflammatory drugs (aspirin, Tylenol, Motrin)
History of antibiotic use
Alcohol consumption or alcohol makes you feel sick
Ulcerative colitis, Crohn's disease or celiac disease
Headaches or migraine headaches
Chronic nasal congestion
Gluten Sensitivity
Choose the number that best describes the intensity of your symptoms. If you do not know the answer to a question, leave it blank.
Bloating and/or gas
Constipation and/or diarrhea
Nausea
Weight trouble
Iron-deficiency anemia
Fatique
Sleep problems
Depression, anxiety and/or mood swings
Menstrual problems
Infertility
Thyroid problems
Osteoporosis or osteopenia
Headaches and/or migraines
Memory problems
Joint pains or aches
Fibromyalgia
Brain fog
Get infections easily
History or family history of arthritis, any type
History or family history of cancer
History or family history of autoimmune disease
History or family history of celiac disease
Colon/large intestine
Choose the number that best describes the intensity of your symptoms. If you do not know the answer to a question, leave it blank.
Seasonal or recurring diarrhea
Frequent and recurrent infections (colds)
Bladder and kidney infections
Vaginal yeast infection
Abdominal cramps
Toe and fingernail fungus
Alternating diarrhea and constipation
Constipation
History of antibiotic use
Meat eater
0 = Never , 1 = Rarely , 2 = often , 3 = daily
Rapidly failing vision
Recurrent stomach pain
Blood or pus in stool