Gut Health Assessment This questionnaire will help you assess your digestive status. It is not meant as a replacement for a physician’s care. This questionnaire will help you discover where your digestive system is having problems. It is a screening tool only and does not constitute a diagnosis of your problem. However, it can point you in the right direction in determining where the highest priorities lie in your healing process. Instructions: Circle the number which best describes the intensity of your symptoms. If you do not know the answer to a question, leave it blank. Add the totals for each section to assess which areas need your attention (keep track of the subtotals along the way so you can easily enter the TOTAL at the end). 0 = Symptom is not present/ rarely present 1 = Mild/sometimes 2 = Moderate/often 3 = Severe/almost alwaysPlease allow 24-48 hours after your submission, for a breakdown of your results and my product recommendations. FIRST NAME(required) LAST NAME(required) EMAIL(required) GASTRIC REFLUX Sour Taste in Mouth 0. 1 2 3 Regurgitate undigested food into mouth 0. 1 2 3 Frequent nocturnal coughing 0. 1 2 3 Burning sensation from citrus on way to stomach 0. 1 2 3 Struggles with muscle tone 0. 1 2 3 Heartburn 0. 1 2 3 Burping 0. 1 2 3 Difficulty swallowing solids or liquids 0. 1 2 3 SUBTOTAL(required) MOOD/SLEEP I feel that I am in a low or depressed mood 0. 1 2 3 My mood fluctuates greatly during day 1 2 3 My mood changes with my menstrual cycle 0. 1 2 3 I feel nervous or worried 0. 1 2 3 I experience anxiety, panic attacks or anxious moments 0. 1 2 3 I often feel grumpy or irritable 0. 1 2 3 I feel overwhelmed 0. 1 2 3 I feel emotionally sensitive or weepy 0. 1 2 3 I wake up in the middle of night, even just to go to bathroom 0. 1 2 3 I don't feel refreshed after a night's sleep 0. 1 2 3 It takes me more than 15 minutes to fall asleep 0. 1 2 3 SUBTOTAL(required) INTESTINAL PERMEABILITY / LEAKY GUT SYNDROME Weight loss plateau 0. 1 2 3 Constipation and/or diarrhea 0. 1 2 3 Abdominal pain or bloating 0. 1 2 3 Mucus or blood in stool 0. 1 2 3 Join pain or swelling, arthritis 0. 1 2 3 Chronic or frequent fatigue or tiredness 0. 1 2 3 Food allergy or food sensitivities or intolerances 0. 1 2 3 Sinus or nasal congestion 0. 1 2 3 Eczema, skin rashes or hives 0. 1 2 3 Dry, flaky skin and brittle hair 0. 1 2 3 Asthma, hayfever or airborne allergies 0. 1 2 3 Confusion, poor memory or mood swings 0. 1 2 3 Use of non steroidal anti-inflammatory drugs (asprin, Tyelnol, Motrin) 0. 1 2 3 History of Antibiotic use 0. 1 2 3 Alcohol consumption or alcohol makes you sick 0. 1 2 3 Autoimmune conditions (ex: Hashimotos, thyroiditis, rheumatoid arthritis, lupus, celiac disease, scleroderma, Addison's disease, Grave's disease, Type 1 diapetes, vitiligo, Psoriasis, etc) 0. 1 2 3 SUBTOTAL(required) COLON/ LARGE INTESTINE / MICROBIOME Seasonal diarrhea 0. 1 2 3 Frequent and recurrent infections (colds) 0. 1 2 3 Bladder and kidney infections 0. 1 2 3 Vaginal yeast infection 0. 1 2 3 Abdominal cramps 0. 1 2 3 Toe and fingernail fungus 0. 1 2 3 Alternating diarrhea/constipation 0. 1 2 3 Constipation 0. 1 2 3 History of antibiotic use 0. 1 2 3 Weight Concerns 0. 1 2 3 Crave sugar and carbs 0. 1 2 3 Meat eater 0. 1 2 3 Conventional dairy 0. 1 2 3 SUBTOTAL (required) TOTAL of all 4 sections TOTAL (required) 0-12= LOW priority 13-27=MODERATE priority 28+=HIGH priority Submit
