Gut Health Questionnaire

Your gut houses large portions of your immune, nervous and endocrine systems and therefore affects every part in your body from your head, to your skin, organs, muscles and joints. The scores you give will indicate what is happening in your whole body and how, by changing your diet, we can heal your body through your gut. When you submit your scores, I will get in touch with you via email to arrange a phone call to discuss. Please ensure that your email address is correct.

Name

First NameLast Name

Email*

example@example.com

Date

Rate each of the following symptoms based upon your typical health profile for the past 30 days:

Head

	0 Never or almost never have the symptom	1 Occasionally have it, effect is not severe	2 Occasionally have it, effect is severe	3 Frequently have it, effect is not severe	4 Frequently have it, effect is severe
Headaches
Faintness/Dizziness

Total

Eyes

	0 Never or almost never have the symptom	1 Occasionally have it, effect is not severe	2 Occasionally have it, effect is severe	3 Frequently have it, effect is not severe	4 Frequently have it, effect is severe
Watery or itchy
Swollen, reddened or sticky eyelids
Bags or dark circles under eyes

Total

Ears

	0 Never or almost never have the symptom	1 Occasionally have it, effect is not severe	2 Occasionally have it, effect is severe	3 Frequently have it, effect is not severe	4 Frequently have it, effect is severe
Itchy
Earaches, ear infections
Ringing in ears, hearing loss

Total

Nose

	0 Never or almost never have the symptom	1 Occasionally have it, effect is not severe	2 Occasionally have it, effect is severe	3 Frequently have it, effect is not severe	4 Frequently have it, effect is severe
Stuffy nose
Sinus problems
Hay fever
Sneezing attacks
Excessive mucus formation

Total

Mouth/Throat

	0 Never or almost never have the symptom	1 Occasionally have it, effect is not severe	2 Occasionally have it, effect is severe	3 Frequently have it, effect is not severe	4 Frequently have it, effect is severe
Chronic coughing
Gagging, frequent need to clear throat
Sore throat, hoarseness, loss of voice
Canker sores

Total

Heart

	0 Never or almost never have the symptom	1 Occasionally have it, effect is not severe	2 Occasionally have it, effect is severe	3 Frequently have it, effect is not severe	4 Frequently have it, effect is severe
Irregular or skipped heartbeat
Rapid or pounding heartbeat
Chest pain

Total

Lungs

	0 Never or almost never have the symptom	1 Occasionally have it, effect is not severe	2 Occasionally have it, effect is severe	3 Frequently have it, effect is not severe	4 Frequently have it, effect is severe
Chest congestion
Asthma, bronchitis
Shortness of breath
Difficulty breathing

Total

Digestive Tract

	0 Never or almost never have the symptom	1 Occasionally have it, effect is not severe	2 Occasionally have it, effect is severe	3 Frequently have it, effect is not severe	4 Frequently have it, effect is severe
Nausea, vomiting
Diarrhoea
Constipation
Bloated feeling
Belching, passing gas
Heartburn/acid reflux
Intestinal/stomach pain

Total

Skin

	0 Never or almost never have the symptom	1 Occasionally have it, effect is not severe	2 Occasionally have it, effect is severe	3 Frequently have it, effect is not severe	4 Frequently have it, effect is severe
Acnes
Hives, rashes, dry skin
Hair loss
Brittle, splitting, ridged nails
Flushing, hot flushes
Excessive sweating

Total

Joints/Muscles

	0 Never or almost never have the symptom	1 Occasionally have it, effect is not severe	2 Occasionally have it, effect is severe	3 Frequently have it, effect is not severe	4 Frequently have it, effect is severe
Pain or aches in joints
Arthritis
Stiffness or limitation of movement
Pain or aches in muscles
Feeling of weakness or tiredness

Total

Weight

	0 Never or almost never have the symptom	1 Occasionally have it, effect is not severe	2 Occasionally have it, effect is severe	3 Frequently have it, effect is not severe	4 Frequently have it, effect is severe
Binge eating/drinking
Craving certain foods
Excessive weight
Compulsive eating
Water retention
Underweight

Total

Mind

	0 Never or almost never have the symptom	1 Occasionally have it, effect is not severe	2 Occasionally have it, effect is severe	3 Frequently have it, effect is not severe	4 Frequently have it, effect is severe
Poor memory
Confusion, poor comprehension
Poor concentration
Poor physical coordination
Difficulty in making decisions
Stuttering or stammering
Slurred speech
Learning disabilities

Total

Emotions

	0 Never or almost never have the symptom	1 Occasionally have it, effect is not severe	2 Occasionally have it, effect is severe	3 Frequently have it, effect is not severe	4 Frequently have it, effect is severe
Mood swings
Anxiety, fear, nervousness
Anger, irritability, aggressiveness
Depression

Total

Energy/Activity

	0 Never or almost never have the symptom	1 Occasionally have it, effect is not severe	2 Occasionally have it, effect is severe	3 Frequently have it, effect is not severe	4 Frequently have it, effect is severe
Fatigue, sluggishness
Apathy, lethargy
Hyperactivity
Restlessness/cramps
Feel the cold
Insomnia

Total

Other

	0 Never or almost never have the symptom	1 Occasionally have it, effect is not severe	2 Occasionally have it, effect is severe	3 Frequently have it, effect is not severe	4 Frequently have it, effect is severe
Frequent illness
Frequent or urgent urination
Genital itch or discharge

Total

Grand Total/276

Note that less than 10 = optimal

More than 50 suggests the presence of significant inflammation and/or toxic load problems.

From Toolbox, Institute for Functional Medicine