Gut Health Questionnaire

Gut Health Questionnaire:
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
SECTION 1: HEALTH HISTORY
For each "yes" answer, score yourself the number of points indicated for that question. For each "no" answer, score yourself 0 points. All answers will automatically add up. No calculator or paper needed.
Have you taken tetracycline or other antibiotics for acne for one month or more?

Score

Total: 0/ 25
Have you taken broad-spectrum antibiotics for any infection for two months or longer, or shorter courses in a one-year period?

Score

Total: 0/ 20
Have you ever been bothered by persistent prostatitis, vaginitis or other problems affecting your reproductive organs?

Score

Total: 0/ 25
Have you been pregnant one time only?

Score

Total: 0/ 3
Have you been pregnant two or more times?

Score

Total: 0/ 5
Have you taken birth control pills less than two years?

Score

Total: 0/ 8
Have you taken birth control pills two or more years?

Score

Total: 0/ 15
Have you taken Prednisone or other cortisone-type drug for less than two weeks?

Score

Total: 0/ 6
Have you taken Prednisone or other cortisone-type drug for more than two weeks?

Score

Total: 0/ 15
Does exposure to fragrances, mall odors or chemicals provoke mild allergic symptoms?

Score

Total: 0/ 5
Does exposure to fragrances, mall odors or chemicals provoke moderate to severe allergic symptoms?

Score

Total: 0/ 20
Are these symptoms worse on damp, muggy days or in moldy places?

Score

Total: 0/ 20
Have you had Mild to moderate athlete’s foot, jock itch, ring worm, or chronic fungus infection of skin or nails?

Score

Total: 0/ 10
Do you crave sugar?

Score

Total: 0/ 10
Do you crave bread?

Score

Total: 0/ 10
Do you crave alcoholic beverages?

Score

Total: 0/ 10
Does tobacco smoke bother you?

Score

Total: 0/ 10
Total Points for Section 1:
SECTION 2: SYMPTOMS (Part 1)
Rate the following symptoms by writing the appropriate score next to each symptom.

0 points - Never experienced

3 points - Occasional or mild

6 points - Frequent and/or moderately severe

9 points - Severe and/or disabling
Fatigue or feeling drained

Total: 0/ 9
Poor memory; feeling spacey or unreal

Total: 0/ 9
Depression

Total: 0/ 9
Numbness, burning or tingling

Total: 0/ 9
Muscle aches, weakness or paralysis

Total: 0/ 9
Pain and/or swelling joints

Total: 0/ 9
Abdominal pain

Total: 0/ 9
Bloating, constipation or diarrhea

Total: 0/ 9
Persistent vaginal burning/itching

Total: 0/ 9
Troublesome vaginal discharge

Total: 0/ 9
Prostatitis

Total: 0/ 9
Impotence or loss of sexual desire

Total: 0/ 9
Endometriosis, PMS, or menstrual irregularities

Total: 0/ 9
Spots in front of the eyes; erratic vision

Total: 0/ 9
Total points for Section 2
SECTION 3: SYMPTOMS (Part 2)
Rate the following symptoms by writing the appropriate score next to each symptom.

0 points - Never experienced

3 points - Occasional or mild

6 points - Frequent and/or moderately severe

9 points - Severe and/or disabling
Frequent drowsiness

Total: 0/ 9
Frequent irritability and/or jitteriness

Total: 0/ 9
Frequent lack of coordination

Total: 0/ 9
Frequent inability to concentrate

Total: 0/ 9
Frequent mood swings (ups & downs)

Total: 0/ 9
Frequent headaches

Total: 0/ 9
Frequent dizziness/loss of balance

Total: 0/ 9
Feeling of head swelling & tingling

Total: 0/ 9
Frequent itching anywhere on body

Total: 0/ 9
Frequent or persistent rashes

Total: 0/ 9
Frequent heartburn and/or indigestion

Total: 0/ 9
Belching, burping & intestinal gas

Total: 0/ 9
Mucus in stools

Total: 0/ 9
Hemorrhoids

Total: 0/ 9
Frequent dry mouth

Total: 0/ 9
Rash or blisters in/around mouth

Total: 0/ 9
Bad breath

Total: 0/ 9
Joint swelling or arthritis

Total: 0/ 9
Nasal congestion, itching or discharge

Total: 0/ 9
Postnasal drip

Total: 0/ 9
Frequent sore or dry throat

Total: 0/ 9
Frequent unexplained cough

Total: 0/ 9
Pain or tightness in chest

Total: 0/ 9
Wheezing or shortness of breath

Total: 0/ 9
Urinary urgency or frequency

Total: 0/ 9
Burning on urination

Total: 0/ 9
Noticeably failing vision

Total: 0/ 9
Recurrent infections or fluid in ears

Total: 0/ 9
Ear pain or deafness

Total: 0/ 9
Total points for Section 3:
TOTAL SCORE:
Choose the best day and time for me to contact you about your scores.
Choose your preferred method of contact
If other than phone, text, or email, please give specific info here. For example, your name on Facebook if you prefer that method of contact.
Should be Empty:

Gut Health Questionnaire:

SECTION 1: HEALTH HISTORY

SECTION 2: SYMPTOMS (Part 1)

SECTION 3: SYMPTOMS (Part 2)