Digestive Evaluation

1

Name* This field is required.

First Name

Last Name

2

Phone Number* This field is required.

Area Code

Phone Number

3

Email* This field is required.

example@example.com

4

Do you have insurance?* This field is required.

Yes

No

5

a. How often do you go #1 a day?

More than 4 times a day

2-3 times a day

Maybe once a day

7

c. Do you strain to go #1 or #2?

Almost always

Often

Sometimes

Hardly ever

8

d. Do you feel like you need to, but can’t go #1 or #2?

Yes

Sometimes

Hardly Ever

9

e. Do you see undigested food in your #2?

Yes

Sometimes

No

10

f. Is your #2 pellets instead of a fully formed (S shape)

Yes

Often

No

11

g. Is there blood when you wipe?

Yes

Sometimes

Very Seldom

12

h.1 Are you relying on band-aids to help digestion & elimination: caffeine or cigarettes

Yes

Sometimes

No

13

h.2 Are you relying on band-aids to help digestion & elimination: medications (Rx or over-the-counter)

Yes

Sometimes

No

14

h.3 Are you relying on band-aids to help digestion & elimination: colonics, detoxes, cleanses?

Yes

Sometimes

No

15

a. Are your things (food, acid, liquids) going the wrong way?

Yes

Often

Hardly Ever

16

b. Do you have reflux; are you taking medication for GERD?

Yes, no medication

Yes, I take medication

Sometimes

No

17

c. Do you have loose stools?

Yes

Often

Sometimes

Hardly Ever

18

d. Are you bloated?

Yes, daily

Often (2-3 days a week)

Hardly ever

19

a. Do you have foul or sweet smelling gas, poop or body odor?

Yes

Sometimes

No

20

b. Do you have bad breath?

Yes

Sometimes

No

21

a. Do you eat better quantities, nutrient balance but still feel hungry soon after?

YESNO

22

b. Do you have low energy after eating?

YESNO

23

c. Do you struggle to lose weight around your middle even though you make better nutrition choices and exercise regularly?

YESNO

24

d. Do you feel bloated after eating?

YESNO

25

e. Do you get in your better water amount daily?

YESNO

26

f. Do you avoid foods due to allergies, intolerances?

YESNO

27

g. Do you skip foods / food groups because you don’t digest them well?

YESNO

28

h. Do you get in a rainbow of colors from plants?

YESNO

29

a. Do you travel where you sit >20 minutes daily?

YESNO

30

b. Do you travel on a plane?

YESNO

31

c. Are you stressed (are you a >5 on a scale of 1-10)

YESNO

32

d. Do you struggle to get 7 hours of good sleep?

YESNO

33

e. Do you exercise vigorously?

YESNO

34

f. Do you sit for >2 hours at a time?

YESNO

35

g. Do you have an injury or illness that keeps you from twisting your upper body (waist), touching your toes, taking steps?

YESNO

36

h. Are you more than 10 pounds overweight?

YESNO

37

i. Do you have a chronic digestive disease or condition?

YESNO

38

j. Do you have a history of taking antibiotics, anti-depressants, birth control, or skin medications (topical or oral)?

YESNO

39

k. Are your pregnant or had a baby(ies) in the last year?

YESNO

40

l. Are you taking / taken hormones?

YESNO

41

m. Are you getting your period?

YESNO

42

a. Do you get yeast, sinus, or ear / throat infections?

YESNO

43

b. Are you taking antibiotics? oral or topical?

YESNO

44

c. Do you get a cold(s) > 1 quarterly (every 3 months)?

YESNO

45

a. Are you breaking out (back, bum, face, arms)?

YESNO

46

b. Do you have bags or dark color under your eyes?

YESNO

47

c. Do you have eczema or chronic skin disease?

YESNO

48

d. Do you have white bumps on your arms?

YESNO

49

a. Do you take a multivitamin?

YESNO

50

b. Do you take a calcium or iron supplement?

YESNO

51

c. Do you take magnesium?

YESNO

52

d. Do you take a probiotic?

YESNO

53

e. Do you take glutamine or collagen?

YESNO

54

f. Are you getting enough fiber?

YESNO

55

g. Do you take a fiber or prebiotic fiber supplement?

YESNO