Gut Health Assessment Quiz

Gut Health Assessment Quiz
NAME
EMAIL
example@example.com
Date

MonthDayYear
Date
Rate each of the symptoms to the best of your ability based on the last 90 days. For Yes/No answers, circle the number next to your answer, if there is a number. Total your score in the space provided. Compare your results with the rating system. A score in the yellow or red range suggests this area is more likely a problem for you.

Drainage Dysfunction Susceptibility

	Never (0)	Occasionally (1)	Often (2)	Regularly (3)
Constipation (pooping one or fewer times daily)
Feeling that bowels do not empty completely
General or chronic fatigue
Mood problems: anxiety, depression, or bipolar
Poor brain processing (cognition)
Chronic inflammation
Wake up between 1 a.m. to 4 a.m.
Edema, swelling or retain extra fluids
Skin problems, rashes, itches, hives, eczema, or acne
Yellowish skin, face
Suppressed immune system
Can't clear infections, despite following pathogen protocols
Sore or swollen breast tissue
Heart palpitations or irregular heartbeat
Light, sound, or EMF sensitivities
Morning stiffness
Brain fog
Swollen glands
Cellulite or flabby skin
Varicose or spider veins
Kidney problems
Breathing or lung issues
Skin doesn't sweat
Puffy Eyes

Drainage Dysfunction Total
Drainage Dysfunction Total Color Code
Drainage Dysfunction Total Color 2

GREEN	YELLOW	RED
0-14	15-35	36-72

	Never (0)	Occasionally (1)	Often (2)	Regularly (3)
Belching or burping
Gas quickly following a meal
Bad breath
Feel full while eating and after meals
Difficulty digesting fruits and vegetables; undigested food found in stools
Stomach pain, burning, or aching 1 to 4 hours after eating
Temporary relief by using antacids, food, milk, or carbonated beverages
Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, or caffeine
Indigestion
Abdominal bloating
Constipation
Diminished appetite

	Never (0)	Occasionally (1)	Often (2)	Regularly (3)
Increased gut motility, diarrhea
Alternating constipation and diarrhea
Mucus in stool
Poorly formed or loose stools
Four or more large stools daily
Stools have foul odor
Suspect nutrient malabsorption
Diagnosed with celiac disease, irritable bowel syndrome (IBS), or diverticulosis/diverticulitis
Stomach cramps
Flatulence (gas)
Fiber-rich diet doesn’t help constipation

	No	Yes(6)
History of pimples or skin eruptions?
Any known food allergies?

	Never (0)	Occasionally (1)	Often (2)	Regularly (3)
Feeling that bowels do not empty completely
Lower abdominal pain relieved by passing stool or gas
Alternating constipation and diarrhea
Constipation
Hard, dry, or small stool
Coated tongue or buildup of debris on tongue
Use laxatives
History of bladder and/or kidney infection
Yeast infection (including vaginal)
Fingernail and/or toenail fungus

	Never (0)	Occasionally (1)	Often (2)	Regularly (3)
Adverse reactions to foods
Unpredictable food reactions
Aches, pains, and swelling throughout your body
Unpredictable abdominal swelling
Food allergies
Frequent bloating and distention after eating

Gut Health Assessment Quiz

Organs

Pathogens

	Never (0)	Occasionally (1)	Often (2)	Regularly (3)
Restless sleep (toss, turn, or wake up often)
Skin issues, rashes, itches, hives, eczema, or acne
Frequent diarrhea or loose stools
Alternating constipation and diarrhea
SIBO (small intestinal bacterial overgrowth), feel bloated or gassy
Bowel urgency, occasional accidents
Abdominal pains, cramps, or burning
Rectal, anal itch
Anal fissures (small, painful tears or cracks)
Stomach or small intestinal ulcers or lesions
Grinding of teeth when asleep
Picking at nose, boring nose with finger
Excess boogers in nose and scab-like boogers
Fingernail biting
Headaches/Migraines
Irritable (no apparent reason)
Mood disorder, depression, anxiety, or suicidal thoughts
Hyperactive tendency (nervous)
Dark circles under eyes
Need for extra sleep, wake unrefreshed
Allergies and/or food sensitivities
Fevers of unknown origin
Night sweats (not menopausal)
Kiss pets, allow pets to lick your face
Increase of symptoms around a full moon
Anemia (low iron/hemoglobin on blood test)
Iron deficiency
Vitamin B6 deficiency
Zinc deficiency and/or white spots on nails
Frequent colds, flu, sore throats
Travel in developing nations
Eat pork products
Eat sushi, raw fish
Sleep with pets on bed
Bed-wetting
Frequent vomiting
Loss of appetite
Hungry all the time, bottomless pit, hungry after meals
Strong sugar and processed food cravings
Breathing problems, asthma
Pain in belly button area (umbilicus)
Blurry, unclear vision
Eye floaters
Lethargy, apathy (disinterest)
Menstrual problems
Dry lips
Drooling while asleep
Occult blood in stool (from lab test)
Swim in creeks, rivers, lakes

	No	Yes(6)
Do you work in childcare?
History of Giardia, pinworms, or other parasites?

	Never (0)	Occasionally (1)	Often (2)	Regularly (3)
Abdominal distention after consuming fiber, starches, or sugar
Abdominal distention after taking certain probiotics or other dietary supplements
Abdominal distention, bloating, or a noisy gut after eating healthy vegetables
Bloating or feeling full in upper abdominal area (just below rib cage)

GREEN	YELLOW	RED
0-11	12-26	27-36

GREEN	YELLOW	RED
0-10	11-24	25-45

GREEN	YELLOW	RED
0-9	10-24	25-36

GREEN	YELLOW	RED
0-7	8-15	16-24