Gut Health Survey Form

Your Name:*

First NameLast Name

Age:*

Sex:*

MaleFemale

Please list your 5 major health concerns in order of importance:*

Please list your top 3 health goals you hope to achieve with the help of a Nutrition Therapy Practitioner?*

EATING HABITS*

I relax & enjoy my food at mealtime.They know me by name at drive thru window.I sometimes eat out but usually pack my lunch.I crave salty snacks (ie potato chips, pretzels, crackers).I crave sweets & carbs (ie bread, chocolate, candy, soda).I experience acid re-flux and/or heartburn after eating.

MOOD/ENERGY*

If I miss a meal, I feel cranky and irritable, weak, or tired.I am often anxious, depressed, moody, impatient.I am tired most of the time.I pop out of bed every morning ready to take on the world.I wake up in the middle of night and have difficulty getting back to sleep.I feel well-rested when I wake up.I have trouble falling asleep at night.

GENERAL HEALTH*

Gallbladder? I had that removed years ago!Headaches or migraines are a daily occurrence.I have been diagnosed with Type 2 Diabetes.I have taken an antibiotic in the last 5 years.I suffer from seasonal allergies.I suffer from skin issues (ie psoriasis, eczema, acne, rosacea, rashes).I take at least 1 prescription medication.I am experiencing memory issues.I have food sensitivities or allergies.

BATHROOM HABITS*

My bowels are like clockwork, same time every day.I experience frequent diarrhea.I depend on laxatives or other aids to ensure a trip to the bathroom.I switch between diarrhea & constipation.The toilet plunger & I are friends.I visit the bathroom more frequently than I'd like to share.

What changes do you feel have improved your health?*

What changes do you feel haven't made a difference?*

What do you feel is standing in your way of reaching your health goals?*

On a scale of 1-10, how willing are you to make recommended improvements in order to achieve your health goals? (1=You Can't Make Me!, 10=I'll Do Whatever It Takes!)*

Who can I thank for referring you, or how did you hear about me?*

Enter a phone number or email address to set up a brief time to discuss your survey results:*

Phone Number or Email

What is the best time to call you?

DateHourMinutesAM/PM Option

Gut Health Survey

Please choose all that apply to you: