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 always


Please allow 24-48 hours after your submission, for a breakdown of your results and my product recommendations.

GASTRIC REFLUX


MOOD/SLEEP


INTESTINAL PERMEABILITY / LEAKY GUT SYNDROME


COLON/ LARGE INTESTINE / MICROBIOME



TOTAL of all 4 sections

0-12= LOW priority 13-27=MODERATE priority 28+=HIGH priority