Gastrointestinal & Digestive Questionnaire
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Part I
Diet and Nutrition
Mark any of the following that you eat regularly.
*
Alcohol
Candy
Coffee
Soda/Pop
Chewing Tobacco
Fried Foods
Fast Food
Dairy (milk, cheese, yogurt)
Sugar & Sweets
Trans Fats
Soy Products
Gluten Containing Products
Alcohol - How many drinks per day? Per week?
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Coffee - How many cups per day?
*
Fast Food - How many times per week?
*
Do you cook meals at home? If yes, how many meal do you eat per day and per week that are made by you?
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How many meals per week do you dine out? (aside from the fast food you noted above)
*
Please describe your current diet
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Part II
Activity and Lifestyle
How many hours a day are you inactive or sitting?
*
How many times do you exercise per week? For how long each time?
*
Do you sweat a lot or a little when you exercise? or not at all?
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How many hours of sleep do you get at night? And do you feel rested when you wake up in the morning?
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What are your normal stress levels? Rank the amount of stress from 1-10 - 1 being none and 10 being tremendous amounts.
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Part III
This part of the questionnaire will help us identify which parts of the digestive tract are causing the most problems or symptoms. 0 = not present at all // 1 = sometimes with mild severity // 2 = often with moderate severity // 3 = severe and very frequent
Low Stomach Acid (0-3 Low, 4-6 Moderate, 7+ High Priority)
*
Rows
0
Not Present
1
Sometimes & Mild
2
Often & Moderate
3
Severe and Very Frequent
Bloating after eating
Poor appetite
Stomach upsets easily
Constipation
Rosacea or acne
Fullness for extended times after meals
Food Allergies
Low iron or anemic
Burping
Nausea after taking supplements or eating
Tested positive for candida or parasites
Take antacids
Add up your total score from the table above.
*
Improper Function of the Pancreas/Small Intestine (0-6 Low, 7-10 Moderate, 11+ High Priority)
*
Rows
0
Not Present
1
Sometimes & Mild
2
Often & Moderate
3
Severe and Very Frequent
Difficulty gaining weight
Multiple Food Allergies
Skin issues or acne (not around jaw line)
Dry skin
Dry or brittle hair
Poor appetite
Stool poorly formed
Slimy stool or mucus in stool
Veggies and fiber cause constipation
Diarrhea
Alternating constipation and diarrhea
Flatulence
Autoimmune conditions present
Tiredness after eating
Shiny Stool
3 or more large bowel movements per day
Chronic stomach pain on left side below ribs
Excessively smelly stools
Nausea
Undigested food in stool
Gallbladder disease or history of gallstones
acid reflux/heartburn/GERD
Diabetes
Osteoporosis
Alcoholism
Add up your total score from the table above.
*
Acid Reflux (0-3 Low, 4-6 Moderate, 7+ Priority)
*
Rows
0
Not Present
1
Sometimes & Mild
2
Often & Moderate
3
Severe and Very Frequent
Sourness taste in mouth regularly
Coughing in the middle of the night
Heartburn
Hard time swallowing foods & liquids
Constant burping especially after meals
Regurgitating undigested food in mouth
Burning in the stomach when eating citrus
Add up your total score from the table above.
*
Too Much Stomach Acid or Possible Ulcers (0-4 Low, 5-8 Moderate, 9+ Priority)
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Rows
0
Not Present
1
Sometimes & Mild
2
Often & Moderate
3
Severe and Very Frequent
Previous regular use of Aspirin or NSAIDS
Black stool (not taking iron supplements)
History of previous ulcer
Family history of ulcers or gastritis
Stomach pain relived by drinking dairy
Carbonated drinks temporarily relieve pain
Frequent indigestion
Frequent burping and bloating
Regular butterflies in stomach feeling
Constant abdominal pain
Antacids required for heartburn and/or acid reflux
Pain in stomach before meals
General stomach pain
Pain in stomach occurs when stressed or upset
Add up your total score from the table above.
*
Gallbladder & Liver Dysfunction (0-2 Low, 5-9 Moderate, 10+ Priority)
*
Rows
0
Not Present
1
Sometimes & Mild
2
Often & Moderate
3
Severe and Very Frequent
Hard time gaining weight
Multiple Food Allergies
Skin issues or acne
Dry skin
Dry or brittle hair
Hard stool
Tiredness after eating
Halitosis or bad breath
Yellowish tint in whites of eyes
Grayish colored skin
Sour taste in mouth
Not having daily bowel movements
Pain radiating on the outside of leg
Pain in the big toe only
Water retention
Painful bowel movements
Foul smelling stool
Light colored stool
Migraines or headaches after eating
Intolerance of greasy foods
Pain in the right side under rib cage
Have had jaundice or hepatitis (No=0, 2+ years ago =1, Current=2, Chronic=3)
Blood in stool (reddish color) (No=0, 2+ years ago =1, Current=2, Chronic=3)
Triglycerides above 115 (No=0, unknown=Blank, Yes=2)
High cholesterol and low HDL (No=0, unknown=Blank, Yes=2)
Cholesterol above 200 (No=0, unknown=Blank, Yes=2)
Add up your total score from the table above.
*
Dysbiosis or Bacterial Overgrowth (1-5 Low, 6-10 Mild, 11-19 Moderate, 20+ Priority)
*
Rows
0
Not Present
1
Sometimes & Mild
2
Often & Moderate
3
Severe and Very Frequent
Bloating
Brain Fog
Have bad breath
Take antacids (ex. Tums)
Have food sensitivities/intolerances
Have severe stress
Have acid reflux/heartburn
Vitamin D Deficiency
Have arthritis or fibromyalgia
Taken antibiotics more than twice in past year
Have trouble digesting beans and fiber
Have trouble digesting carbs
Depressed or anxious all the time
Have sinus congestion
Constipation
Chronic diarrhea
Often get stomach bugs
Have cramps after you eat
Have mucus or blood in stool
Diagnosed with autoimmune disease or condition
Add up your total score from the table above.
*
Possible Small Intestinal Bacterial Overgrowth - SIBO (0-4 Low, 5-9 Moderate, 10+ High Priority)
*
Rows
0
Not Present
1
Sometimes & Mild
2
Often & Moderate
3
Severe and Very Frequent
Currently taking antacids or PPI's for heartburn or GERD
Excessive Gas/Flatulence
Abdominal Pain
Fibromyalgia
Diarrhea
Intolerance to probiotic and prebiotic supplements
Abdominal bloating and distension, especially with carbs such as sugar and fiber
IBS
Restless leg syndrome
Scored 9 or more on LOW stomach acid section
Add up your total score from the table above.
*
Low Digestive Enzyme Production (0-6 Low, 7-10 Moderate, 10+ High Priority)
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Rows
0
Not Present
1
Sometimes & Mild
2
Often & Moderate
3
Severe and Very Frequent
Take antacids or acid blocking meds
Have glucose intolerance
Have food sensitivities/intolerances
Bruise easily (can also be low Vitamin K)
B12 Deficiency
Ankles Swell
Does not have a daily bowel movement
Have foul smelling stools
Bad breath
Fullness after a meal
Indigestion after meals
Bloating after meals
Belching or flatulence after eating
Abdominal bloating or swelling
Undigested food in stool
Signs of poor digestion of fatty foods
Weak, peeling or cracked fingernails
Any skin condition
Recurring headaches
Depression
Fatigue in spite of a good diet and regular sleep
Inability to gain muscle despite weight training
Often eat in a rush
Not chew your food properly/thoroughly
Add up your total score from the table above.
*
Leaky Gut or Intestinal Permeability (0-5 Low, 6-10 Mild, 11-19 Moderate, 20+ High Priority)
*
Rows
0
Not Present
1
Sometimes & Mild
2
Often & Moderate
3
Severe and Very Frequent
Chronic sinus or nasal congestion
Headaches or migraines
History of antibiotic use
Chronic and frequent inflammation
Chronic or frequent fatigue
Mucus or blood in stool
Constipation and/or diarrhea
Eczema, skin conditions or hives
Ulcerative colitis, Chrons, Celiac
Use of non-steroidal anti-inflammatory drugs (Aspirin, Tylenol, Motrin, Ibuprofen)
Tiredness after eating
Halitosis or bad breath
Asthma, hay fever or airborne allergies
Food allergy or food intolerances
Joint pain/swelling/arthritis
Abdominal pain or bloating
Confusion/poor memory/mood swings
Light colored stool
Alcohol consumption or alcohol makes you feel sick
Add up your total score from the table above.
*
Gluten Sensitivity (0-6 Low, 7-10 Moderate, 11+ High Priority)
*
Rows
0
Not Present
1
Sometimes & Mild
2
Often & Moderate
3
Severe and Very Frequent
Brain fog
Fibromyalgia
Achy joints or chronic joint pain
Memory issues
Headaches or migraines
Fatigue
Get infections easily
Menstrual problems
Infertility
Thyroid problems
Anemic or iron deficiency anemia
Have a hard time losing weight
Nausea
Constipation and/or diarrhea
Bloating and/or gas
Osteoporosis or osteopenia
Family history of cancer
Family history of arthritis
Family history of autoimmune disease
Family history of celiac disease
Add up your total score from the table above.
*
Large Intestine or Colon Problems (0-5 Low, 6-9 Moderate, 10+ High Priority)
*
Rows
0
Not Present
1
Sometimes & Mild
2
Often & Moderate
3
Severe and Very Frequent
Family history of inflammatory bowel disease (IBD)
Blood or pus in stool
Recurrent stomach pain
Failing vision
History of antibiotic use
Constipation
Vaginal yeast infections or oral thrush
Bladder and kidney infections
Frequent and recurrent infections
Seasonal or recurring diarrhea
Alternating diarrhea and constipation
Toe and fingernail fungus
Abdominal cramping
Add up your total score from the table above.
*
Submit
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