Alta's Gut Health Self-Assessment
Please fill out this form to the best of your knowledge so we can better assist you.
Name
*
First Name
Last Name
Email
*
example@example.com
Gender at Birth
*
Male
Female
Age
*
Height (feet inch)
*
Weight (lb)
*
I experience diarrhea:
*
Never
Rarely
Sometimes
Always (daily or almost daily)
I experience constipation:
*
Never
Rarely
Sometimes
Always (daily or almost daily)
I have foul smelling gas:
*
Never
Rarely
Sometimes
Always (daily or almost daily)
I have difficulty digesting fruits and vegetables; undigested food in stools:
*
Never
Rarely
Sometimes
Always (daily or almost daily)
I feel that bowels do not empty completely:
*
Never
Rarely
Sometimes
Always (daily or almost daily)
I experience gas immediately following a meal:
*
Never
Rarely
Sometimes
Always (daily or almost daily)
I experience heartburn:
*
Never
Rarely
Sometimes
Always (daily or almost daily)
I use antacids:
*
Never
Rarely
Sometimes
Always (daily or almost daily)
I use antacids:
*
Never
Rarely
Sometimes
Always (daily or almost daily)
I have difficulty losing weight:
*
Never
Rarely
Sometimes
Always (daily or almost daily)
I experience coated tongue or “fuzzy” debris on tongue:
*
Never
Rarely
Sometimes
Always (daily or almost daily)
I have skin conditions like eczema, psoriasis, atopic dermatitis:
*
Never
Rarely
Sometimes
Always (daily or almost daily)
I experience abdominal bloating, distention and discomfort:
*
Never
Rarely
Sometimes
Always (daily or almost daily)
Phone # (optional). If you would like us to text you, instead of email you, to give you advice on your gut health please provide your phone #:
Please enter a valid phone number.
Format: (000) 000-0000.
Your total score:
Calculate
Should be Empty: