Digestive Intake Form

1
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5
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6
Please Describe The Typical Appearance of Your Stool
Type 1: Separate hard lumps, like nuts (hard to pass)
Type 2: Sausage-shaped, but lumpy
Type 3: Like a sausage but with cracks on its surface
Type 4: Like a sausage or snake, smooth and soft
Type 5: Soft blobs with clear cut edges (passed easily)
Type 6: Fluffy pieces with ragged edges, a mushy stool
Type 7: Watery, no solid pieces. Entirely liquid
7
Feel freee to add additional comments here
8
Section A: Upper GI dysfunction and Motility
Almost Never(0)
Sometimes (1)
Often (2)
Most of the time (3)
Burning or Belching
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Heartburn or Acid Reflux
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
nausea or vomiting after eating
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Stomach Easily Upset After Eating
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Bloating in the stomach
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Upper Abdomen Immediately Full After Eating.
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Feeling Undigested Food Sitting In The Stomach
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Uncomfortable Fullness After Eating
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Loss of appetite or desire for food
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Bad Breath or Bitter Taste in Mouth
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Fullness after Small Meals
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Burning or Belching
Heartburn or Acid Reflux
nausea or vomiting after eating
Stomach Easily Upset After Eating
Bloating in the stomach
Upper Abdomen Immediately Full After Eating.
Feeling Undigested Food Sitting In The Stomach
Uncomfortable Fullness After Eating
Loss of appetite or desire for food
Bad Breath or Bitter Taste in Mouth
Fullness after Small Meals
Almost Never(0)
Row 0, Column 0
Sometimes (1)
Row 0, Column 1
Often (2)
Row 0, Column 2
Most of the time (3)
Row 0, Column 3
Almost Never(0)
Row 1, Column 0
Sometimes (1)
Row 1, Column 1
Often (2)
Row 1, Column 2
Most of the time (3)
Row 1, Column 3
Almost Never(0)
Row 2, Column 0
Sometimes (1)
Row 2, Column 1
Often (2)
Row 2, Column 2
Most of the time (3)
Row 2, Column 3
Almost Never(0)
Row 3, Column 0
Sometimes (1)
Row 3, Column 1
Often (2)
Row 3, Column 2
Most of the time (3)
Row 3, Column 3
Almost Never(0)
Row 4, Column 0
Sometimes (1)
Row 4, Column 1
Often (2)
Row 4, Column 2
Most of the time (3)
Row 4, Column 3
Almost Never(0)
Row 5, Column 0
Sometimes (1)
Row 5, Column 1
Often (2)
Row 5, Column 2
Most of the time (3)
Row 5, Column 3
Almost Never(0)
Row 6, Column 0
Sometimes (1)
Row 6, Column 1
Often (2)
Row 6, Column 2
Most of the time (3)
Row 6, Column 3
Almost Never(0)
Row 7, Column 0
Sometimes (1)
Row 7, Column 1
Often (2)
Row 7, Column 2
Most of the time (3)
Row 7, Column 3
Almost Never(0)
Row 8, Column 0
Sometimes (1)
Row 8, Column 1
Often (2)
Row 8, Column 2
Most of the time (3)
Row 8, Column 3
Almost Never(0)
Row 9, Column 0
Sometimes (1)
Row 9, Column 1
Often (2)
Row 9, Column 2
Most of the time (3)
Row 9, Column 3
Almost Never(0)
Row 10, Column 0
Sometimes (1)
Row 10, Column 1
Often (2)
Row 10, Column 2
Most of the time (3)
Row 10, Column 3
1 of 11
9
Upper GI dysfunction Score
10
Section B. Malaborption. Click on the section that describes your symptoms
Almost Never(0)
Sometimes (1)
Often (2)
Most of the time (3)
Bloating 1-3 hours after eating
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Foul-smelling stools or gas
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Shiny, loose, or floating stools
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Undigested food in stools
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Difficulty gaining weight
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Nutrient deficiencies (if known)
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Weak/brittle nails or hair loss
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Fatigue After Meals
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Muscle Weakness Or Cramping
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Poor Wound Healing
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Bloating 1-3 hours after eating
Foul-smelling stools or gas
Shiny, loose, or floating stools
Undigested food in stools
Difficulty gaining weight
Nutrient deficiencies (if known)
Weak/brittle nails or hair loss
Fatigue After Meals
Muscle Weakness Or Cramping
Poor Wound Healing
Almost Never(0)
Row 0, Column 0
Sometimes (1)
Row 0, Column 1
Often (2)
Row 0, Column 2
Most of the time (3)
Row 0, Column 3
Almost Never(0)
Row 1, Column 0
Sometimes (1)
Row 1, Column 1
Often (2)
Row 1, Column 2
Most of the time (3)
Row 1, Column 3
Almost Never(0)
Row 2, Column 0
Sometimes (1)
Row 2, Column 1
Often (2)
Row 2, Column 2
Most of the time (3)
Row 2, Column 3
Almost Never(0)
Row 3, Column 0
Sometimes (1)
Row 3, Column 1
Often (2)
Row 3, Column 2
Most of the time (3)
Row 3, Column 3
Almost Never(0)
Row 4, Column 0
Sometimes (1)
Row 4, Column 1
Often (2)
Row 4, Column 2
Most of the time (3)
Row 4, Column 3
Almost Never(0)
Row 5, Column 0
Sometimes (1)
Row 5, Column 1
Often (2)
Row 5, Column 2
Most of the time (3)
Row 5, Column 3
Almost Never(0)
Row 6, Column 0
Sometimes (1)
Row 6, Column 1
Often (2)
Row 6, Column 2
Most of the time (3)
Row 6, Column 3
Almost Never(0)
Row 7, Column 0
Sometimes (1)
Row 7, Column 1
Often (2)
Row 7, Column 2
Most of the time (3)
Row 7, Column 3
Almost Never(0)
Row 8, Column 0
Sometimes (1)
Row 8, Column 1
Often (2)
Row 8, Column 2
Most of the time (3)
Row 8, Column 3
Almost Never(0)
Row 9, Column 0
Sometimes (1)
Row 9, Column 1
Often (2)
Row 9, Column 2
Most of the time (3)
Row 9, Column 3
1 of 10
11
Malabsorption Score
12
Section C: Intestinal Permeability Click on the section that describes your symptoms
almost never (0)
Sometimes (1)
Often (2)
Most of the time (3)
Known or suspected food allergies, sensitivities, or intolerances
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Mucus or blood in stool
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Joint pain, swelling, or arthritis
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Chronic or frequent fatigue or tiredness
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Brain fog, confusion, or poor memory
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Eczema, skin rashes, hives, or acne
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Chronic inflammation or inflammatory conditions
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Autoimmune condition(s) diagnosed or suspected
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Sinus or nasal congestion
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Mood swings, anxiety, or depression
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Use of NSAIDs (aspirin, ibuprofen, anti-inflammatory drugs)
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
History of prolonged antibiotic or corticosteroid use
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Row 11, Column 3
Known or suspected food allergies, sensitivities, or intolerances
Mucus or blood in stool
Joint pain, swelling, or arthritis
Chronic or frequent fatigue or tiredness
Brain fog, confusion, or poor memory
Eczema, skin rashes, hives, or acne
Chronic inflammation or inflammatory conditions
Autoimmune condition(s) diagnosed or suspected
Sinus or nasal congestion
Mood swings, anxiety, or depression
Use of NSAIDs (aspirin, ibuprofen, anti-inflammatory drugs)
History of prolonged antibiotic or corticosteroid use
almost never (0)
Row 0, Column 0
Sometimes (1)
Row 0, Column 1
Often (2)
Row 0, Column 2
Most of the time (3)
Row 0, Column 3
almost never (0)
Row 1, Column 0
Sometimes (1)
Row 1, Column 1
Often (2)
Row 1, Column 2
Most of the time (3)
Row 1, Column 3
almost never (0)
Row 2, Column 0
Sometimes (1)
Row 2, Column 1
Often (2)
Row 2, Column 2
Most of the time (3)
Row 2, Column 3
almost never (0)
Row 3, Column 0
Sometimes (1)
Row 3, Column 1
Often (2)
Row 3, Column 2
Most of the time (3)
Row 3, Column 3
almost never (0)
Row 4, Column 0
Sometimes (1)
Row 4, Column 1
Often (2)
Row 4, Column 2
Most of the time (3)
Row 4, Column 3
almost never (0)
Row 5, Column 0
Sometimes (1)
Row 5, Column 1
Often (2)
Row 5, Column 2
Most of the time (3)
Row 5, Column 3
almost never (0)
Row 6, Column 0
Sometimes (1)
Row 6, Column 1
Often (2)
Row 6, Column 2
Most of the time (3)
Row 6, Column 3
almost never (0)
Row 7, Column 0
Sometimes (1)
Row 7, Column 1
Often (2)
Row 7, Column 2
Most of the time (3)
Row 7, Column 3
almost never (0)
Row 8, Column 0
Sometimes (1)
Row 8, Column 1
Often (2)
Row 8, Column 2
Most of the time (3)
Row 8, Column 3
almost never (0)
Row 9, Column 0
Sometimes (1)
Row 9, Column 1
Often (2)
Row 9, Column 2
Most of the time (3)
Row 9, Column 3
almost never (0)
Row 10, Column 0
Sometimes (1)
Row 10, Column 1
Often (2)
Row 10, Column 2
Most of the time (3)
Row 10, Column 3
almost never (0)
Row 11, Column 0
Sometimes (1)
Row 11, Column 1
Often (2)
Row 11, Column 2
Most of the time (3)
Row 11, Column 3
1 of 12
13
Intestinal Permeability Score
14
D. Microbiome Balance
almost never (0)
Sometimes (1)
Often (2)
Most of the time (3)
Constipation and/or diarrhea (alternating or chronic)
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Bloating in lower abdomen
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Excessive gas or flatulence
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Abdominal cramping or pain
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
History of antibiotic use (past 1-2 years)
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Sugar or carbohydrate cravings
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Yeast infections (vaginal, oral thrush, athlete's foot)
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Recent travel or food poisoning episode
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Have taken probiotics with noticeable improvement
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
White coating on tongue
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Alcohol consumption (regular)
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Constipation and/or diarrhea (alternating or chronic)
Bloating in lower abdomen
Excessive gas or flatulence
Abdominal cramping or pain
History of antibiotic use (past 1-2 years)
Sugar or carbohydrate cravings
Yeast infections (vaginal, oral thrush, athlete's foot)
Recent travel or food poisoning episode
Have taken probiotics with noticeable improvement
White coating on tongue
Alcohol consumption (regular)
almost never (0)
Row 0, Column 0
Sometimes (1)
Row 0, Column 1
Often (2)
Row 0, Column 2
Most of the time (3)
Row 0, Column 3
almost never (0)
Row 1, Column 0
Sometimes (1)
Row 1, Column 1
Often (2)
Row 1, Column 2
Most of the time (3)
Row 1, Column 3
almost never (0)
Row 2, Column 0
Sometimes (1)
Row 2, Column 1
Often (2)
Row 2, Column 2
Most of the time (3)
Row 2, Column 3
almost never (0)
Row 3, Column 0
Sometimes (1)
Row 3, Column 1
Often (2)
Row 3, Column 2
Most of the time (3)
Row 3, Column 3
almost never (0)
Row 4, Column 0
Sometimes (1)
Row 4, Column 1
Often (2)
Row 4, Column 2
Most of the time (3)
Row 4, Column 3
almost never (0)
Row 5, Column 0
Sometimes (1)
Row 5, Column 1
Often (2)
Row 5, Column 2
Most of the time (3)
Row 5, Column 3
almost never (0)
Row 6, Column 0
Sometimes (1)
Row 6, Column 1
Often (2)
Row 6, Column 2
Most of the time (3)
Row 6, Column 3
almost never (0)
Row 7, Column 0
Sometimes (1)
Row 7, Column 1
Often (2)
Row 7, Column 2
Most of the time (3)
Row 7, Column 3
almost never (0)
Row 8, Column 0
Sometimes (1)
Row 8, Column 1
Often (2)
Row 8, Column 2
Most of the time (3)
Row 8, Column 3
almost never (0)
Row 9, Column 0
Sometimes (1)
Row 9, Column 1
Often (2)
Row 9, Column 2
Most of the time (3)
Row 9, Column 3
almost never (0)
Row 10, Column 0
Sometimes (1)
Row 10, Column 1
Often (2)
Row 10, Column 2
Most of the time (3)
Row 10, Column 3
1 of 11
15
Microbiome Imbalance Score
16
E. Liver /Detoxification
almost never (0)
Sometimes (1)
Often (2)
Most of the time (3)
Dislike or can't tolerate fatty foods
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Headaches after eating (especially fatty meals)
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Light-colored or pale stools
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Constipation or hard stools
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Oily skin or acne
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Pain or tenderness under right side of ribs
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Elevated cholesterol or triglycerides (if known)
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Hemorrhoids or varicose veins
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Sensitivity to chemicals, fragrances, or alcohol
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Difficulty waking up or morning fatigue
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
History of gallbladder issues or removal
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Dislike or can't tolerate fatty foods
Headaches after eating (especially fatty meals)
Light-colored or pale stools
Constipation or hard stools
Oily skin or acne
Pain or tenderness under right side of ribs
Elevated cholesterol or triglycerides (if known)
Hemorrhoids or varicose veins
Sensitivity to chemicals, fragrances, or alcohol
Difficulty waking up or morning fatigue
History of gallbladder issues or removal
almost never (0)
Row 0, Column 0
Sometimes (1)
Row 0, Column 1
Often (2)
Row 0, Column 2
Most of the time (3)
Row 0, Column 3
almost never (0)
Row 1, Column 0
Sometimes (1)
Row 1, Column 1
Often (2)
Row 1, Column 2
Most of the time (3)
Row 1, Column 3
almost never (0)
Row 2, Column 0
Sometimes (1)
Row 2, Column 1
Often (2)
Row 2, Column 2
Most of the time (3)
Row 2, Column 3
almost never (0)
Row 3, Column 0
Sometimes (1)
Row 3, Column 1
Often (2)
Row 3, Column 2
Most of the time (3)
Row 3, Column 3
almost never (0)
Row 4, Column 0
Sometimes (1)
Row 4, Column 1
Often (2)
Row 4, Column 2
Most of the time (3)
Row 4, Column 3
almost never (0)
Row 5, Column 0
Sometimes (1)
Row 5, Column 1
Often (2)
Row 5, Column 2
Most of the time (3)
Row 5, Column 3
almost never (0)
Row 6, Column 0
Sometimes (1)
Row 6, Column 1
Often (2)
Row 6, Column 2
Most of the time (3)
Row 6, Column 3
almost never (0)
Row 7, Column 0
Sometimes (1)
Row 7, Column 1
Often (2)
Row 7, Column 2
Most of the time (3)
Row 7, Column 3
almost never (0)
Row 8, Column 0
Sometimes (1)
Row 8, Column 1
Often (2)
Row 8, Column 2
Most of the time (3)
Row 8, Column 3
almost never (0)
Row 9, Column 0
Sometimes (1)
Row 9, Column 1
Often (2)
Row 9, Column 2
Most of the time (3)
Row 9, Column 3
almost never (0)
Row 10, Column 0
Sometimes (1)
Row 10, Column 1
Often (2)
Row 10, Column 2
Most of the time (3)
Row 10, Column 3
1 of 11
17
Liver /Detoxification Score
18
F. Section Loss of Tolerance
almost never (0)
Sometimes (1)
Often (2)
Most of the time (3)
Increasing number of food sensitivities over time
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Reacting to foods you previously tolerated well
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Multiple chemical sensitivities (fragrances, cleaning products, etc.)
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Seasonal allergies worsening or new onset
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Reactions to supplements or medications you previously tolerated
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Histamine intolerance symptoms (flushing, headaches, hives after certain foods)
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Environmental sensitivities increasing
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Unexplained skin reactions or rashes
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Cyclical symptoms that come and go
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Cross-reactivity patterns (multiple foods in same family)
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Asthma, hay fever, or airborne allergies
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Eczema or skin reactions to environmental triggers
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Row 11, Column 3
Increasing number of food sensitivities over time
Reacting to foods you previously tolerated well
Multiple chemical sensitivities (fragrances, cleaning products, etc.)
Seasonal allergies worsening or new onset
Reactions to supplements or medications you previously tolerated
Histamine intolerance symptoms (flushing, headaches, hives after certain foods)
Environmental sensitivities increasing
Unexplained skin reactions or rashes
Cyclical symptoms that come and go
Cross-reactivity patterns (multiple foods in same family)
Asthma, hay fever, or airborne allergies
Eczema or skin reactions to environmental triggers
almost never (0)
Row 0, Column 0
Sometimes (1)
Row 0, Column 1
Often (2)
Row 0, Column 2
Most of the time (3)
Row 0, Column 3
almost never (0)
Row 1, Column 0
Sometimes (1)
Row 1, Column 1
Often (2)
Row 1, Column 2
Most of the time (3)
Row 1, Column 3
almost never (0)
Row 2, Column 0
Sometimes (1)
Row 2, Column 1
Often (2)
Row 2, Column 2
Most of the time (3)
Row 2, Column 3
almost never (0)
Row 3, Column 0
Sometimes (1)
Row 3, Column 1
Often (2)
Row 3, Column 2
Most of the time (3)
Row 3, Column 3
almost never (0)
Row 4, Column 0
Sometimes (1)
Row 4, Column 1
Often (2)
Row 4, Column 2
Most of the time (3)
Row 4, Column 3
almost never (0)
Row 5, Column 0
Sometimes (1)
Row 5, Column 1
Often (2)
Row 5, Column 2
Most of the time (3)
Row 5, Column 3
almost never (0)
Row 6, Column 0
Sometimes (1)
Row 6, Column 1
Often (2)
Row 6, Column 2
Most of the time (3)
Row 6, Column 3
almost never (0)
Row 7, Column 0
Sometimes (1)
Row 7, Column 1
Often (2)
Row 7, Column 2
Most of the time (3)
Row 7, Column 3
almost never (0)
Row 8, Column 0
Sometimes (1)
Row 8, Column 1
Often (2)
Row 8, Column 2
Most of the time (3)
Row 8, Column 3
almost never (0)
Row 9, Column 0
Sometimes (1)
Row 9, Column 1
Often (2)
Row 9, Column 2
Most of the time (3)
Row 9, Column 3
almost never (0)
Row 10, Column 0
Sometimes (1)
Row 10, Column 1
Often (2)
Row 10, Column 2
Most of the time (3)
Row 10, Column 3
almost never (0)
Row 11, Column 0
Sometimes (1)
Row 11, Column 1
Often (2)
Row 11, Column 2
Most of the time (3)
Row 11, Column 3
1 of 12
19
Loss of tolerance
20
G. Gut-Brain Axis
almost never (0)
Sometimes (1)
Often (2)
Most of the time (3)
Anxiety or nervousness
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Depression or low mood
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Mood swings or irritability
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Poor concentration or mental clarity
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Sleep disturbances or insomnia
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Digestive symptoms worsen with stress
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Loss of appetite or increased eating with stress
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
History of trauma or chronic stress
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
"Butterflies" or nervous stomach feeling
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Gut symptoms improve when relaxed or on vacation
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Brain fog after certain meals
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Anxiety or nervousness
Depression or low mood
Mood swings or irritability
Poor concentration or mental clarity
Sleep disturbances or insomnia
Digestive symptoms worsen with stress
Loss of appetite or increased eating with stress
History of trauma or chronic stress
"Butterflies" or nervous stomach feeling
Gut symptoms improve when relaxed or on vacation
Brain fog after certain meals
almost never (0)
Row 0, Column 0
Sometimes (1)
Row 0, Column 1
Often (2)
Row 0, Column 2
Most of the time (3)
Row 0, Column 3
almost never (0)
Row 1, Column 0
Sometimes (1)
Row 1, Column 1
Often (2)
Row 1, Column 2
Most of the time (3)
Row 1, Column 3
almost never (0)
Row 2, Column 0
Sometimes (1)
Row 2, Column 1
Often (2)
Row 2, Column 2
Most of the time (3)
Row 2, Column 3
almost never (0)
Row 3, Column 0
Sometimes (1)
Row 3, Column 1
Often (2)
Row 3, Column 2
Most of the time (3)
Row 3, Column 3
almost never (0)
Row 4, Column 0
Sometimes (1)
Row 4, Column 1
Often (2)
Row 4, Column 2
Most of the time (3)
Row 4, Column 3
almost never (0)
Row 5, Column 0
Sometimes (1)
Row 5, Column 1
Often (2)
Row 5, Column 2
Most of the time (3)
Row 5, Column 3
almost never (0)
Row 6, Column 0
Sometimes (1)
Row 6, Column 1
Often (2)
Row 6, Column 2
Most of the time (3)
Row 6, Column 3
almost never (0)
Row 7, Column 0
Sometimes (1)
Row 7, Column 1
Often (2)
Row 7, Column 2
Most of the time (3)
Row 7, Column 3
almost never (0)
Row 8, Column 0
Sometimes (1)
Row 8, Column 1
Often (2)
Row 8, Column 2
Most of the time (3)
Row 8, Column 3
almost never (0)
Row 9, Column 0
Sometimes (1)
Row 9, Column 1
Often (2)
Row 9, Column 2
Most of the time (3)
Row 9, Column 3
almost never (0)
Row 10, Column 0
Sometimes (1)
Row 10, Column 1
Often (2)
Row 10, Column 2
Most of the time (3)
Row 10, Column 3
1 of 11
21
Gut Brain Axis Score
22
Which of the following do you have any known or suspected sensitivities to.
Gluten
Milk
Corn
Soy
Eggs
Nightshades
Other (please explain)
23
Feel free to add additional comments here
24
Would you like Dr. Rinde to contact you regarding this form?
YESNO
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