7 Major Gene Nutritional Symptom Questionnaire

7 Major Gene Nutritional Symptom Questionnaire

This questionnaire is not designed to diagnose any medical conditions. It is merely for informational and educational purposes.
This questionnaire will take you about 20-40 minutes to complete. If you'd like to complete it in parts, check your email for login details on returning back to finish it.

There are 8 parts to this questionnaire. Each one will take you about 4-6 minutes to complete.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Part 1 of 8: Daily Meals and Diet
Describe your daily breakfast. Include all foods, drinks, supplements, etc. *
Include any supplements or medications you take. Also, include any beverages you have with any meals like coffee, tea, shakes, wine/alcohol, sports drinks, etc.
Describe your daily lunch. Include all foods, drinks, supplements, etc. *
Include any supplements or medications you take. Also, include any beverages you have with any meals like coffee, tea, shakes, wine/alcohol, sports drinks, etc.
Describe your daily dinner. Include all foods, drinks, supplements, etc. *
Include any supplements or medications you take. Also, include any beverages you have with any meals like coffee, tea, shakes, wine/alcohol, sports drinks, etc.
Describe your daily snacks.*
Include any foods you eat to satisfy any cravings.
Part 2 of 8: DAO Gene

These series of questions will look at the DAO gene which is associated with food sensitivity and histamine reactions.
Do you experience any of these symptoms? Check all that apply.*

Allergic reactions such as hives, runny nose, itchiness and food sensitivitiesCar sickness and seasicknessLeaky gutMigraineNausea/indigestionPregnancy complicationsNone of the above
BASIC SYMPTOMS: Indicate if you have any of these basic symptoms. Check all that apply.*

I tend to suffer from one or more of the following symptoms after eating leftovers, citrus, or fish: irritability, sweatiness, nose-bleeds, runny nose, racing pulse, and/or headacheI’m sensitive to red wine or alcoholI’m sensitive to many foods or suffer from leaky gut syndromeI generally feel better two or three hours after a meal as compared to twenty minutes after eatingI felt better during pregnancy and could eat more varied foodsNone of the above
DAO Gene Basic Symptom Score*
Basic Symptom scoring for the DAO Gene:

0: Gene is functioning well

1: Gene needs attention but other genes may be the issue

2: Gene is mutated and not working at its optimal

3-5: Gene is definitely mutated and not functioning properly
DEEP DIVE SYMPTOMS: Indicate if you experience any of these symptoms. Check all that apply.*

I'm often irritable, hot, or itchy after eatingI can't tolerate yogurt, kefir, sauerkraut, chocolate, alcohol, citrus, fish, wine (especially red) or cheeseI get random joint pains that move around and come and goI have skin issues such as eczema, urticarial (hives), or psoriasisIf I scratch my skin, I get red streaks for several minutesI can't tolerate many probioticsI have a lot of food allergies or food intolerancesI have ringing in my ears at times, especially after eatingI've been told I have leaky gut syndrome, Crohn's disease, or ulcerative colitisI get migraines or other headaches oftenI have a runny nose often or congestedI have nose bleeds oftenI can't fall asleep for several hours after eating or drinkingI have asthma or exercise-induced asthmaNone of the above
DAO Gene Deep Dive Symptom Score*
Deep Dive Symptom scoring for the DAO Gene:

0: Gene is functioning well

1-4: Gene needs attention but other genes may be the issue

5-7: Gene is mutated and not working at its optimal

8+: Gene is definitely mutated and not functioning properly. If other high scoring gene are present, they will be affecting this one most likely
Additional Symptoms. Check all that apply:*

I’m frequently itchyI have sweaty feetI often get heartburn and frequently need an antacidMy eyes often itchI get carsick, seasick, or generally feel dizzyI frequently take antihistaminesI have trouble falling or staying asleepI have blood pressure that’s lower than 100/60I frequently have joint painI have an arrhythmiaWhen I was pregnant, I could eat more foods than usual without symptomsI get side effects from morphine, metformin, NSAIDs, antacids, clonidine, isoniazid, pentamidine, and/or amilorideNone of the above
Part 3 of 8: PEMT Gene

These series of questions will look at the PEMT gene which is associated with cell membranes, liver function and gallbladder function
BASIC SYMPTOMS: Indicate if you have any of these basic symptoms. Check all that apply.*

I tend to have generalized muscle painI notice I have general fatigue or muscle weaknessI have been diagnosed with fatty liverI am a vegetarian/vegan or I don’t eat much beef, organ meat, caviar, or eggsI have gallstones or have had my gallbladder removedI have been diagnosed with small intestine bacterial overgrowth (SIBO)None of the above
PEMT Gene Basic Symptom Score*
Basic Symptom scoring for the PEMT Gene:

0: Gene is functioning well

1: Gene needs attention but other genes may be the issue

2: Gene is mutated and not working at its optimal

3-6: Gene is definitely mutated and not functioning properly
DEEP DIVE SYMPTOMS: Indicate if you experience any of these symptoms. Check all that apply.*

I'm postmenopausalMy estrogen levels are lowI have gallstonesI don't eat leafy green vegetables oftenI don't eat eggs or meat muchI've been told I have fatty liverI have SIBOI'm a vegetarian or veganI've had my gallbladder removedI've had General Pain everywhere - inside and out - for yearsI don't tolerate fatty foods wellMy gallbladder symptoms started partway through pregnancy and I've gotten much worseMy child has a congenital birth defectBreastfeeding wore me out physically and mentallyNone of the above
PEMT Gene Deep Dive Symptom Score*
Deep Dive Symptom scoring for the PEMT Gene:

0: Gene is functioning well

1-4: Gene needs attention but other genes may be the issue

5-7: Gene is mutated and not working at its optimal

8+: Gene is definitely mutated and not functioning properly. If other high scoring gene are present, they will be affecting this one most likely
Additional Symptoms. Check all that apply:*

I've had genetic testing which shows MTHFD1 or MTHFR C677T polymorphismI’m vitamin B12 deficientI'm intolerant of fatty foodsMy estrogen levels are lowI take antacidsI have pain or discomfort in the upper right quadrant of my abdomenMy right shoulder is tight by my scapulaI tend to have constipationI tend to be itchyNone of the above
Part 4 of 8: GST/GPX Gene

These series of questions will look at the GST/GPX gene which is associated with sensitivity to chemicals and smells as well as the production of glutathione
Do you experience any of these GST gene symptoms? Check all that apply.*

Hypersensitivity to chemicals: Congestion, runny nose, watery eyes, coughing, sneezing, fatigue, migraine, rashes, Hives, digestive issues, anxiety, depression, and brain fogIncreased inflammationHigh blood pressureOverweight/obesityNausea/indigestionPregnancy complicationsNone of the above
Do you experience any of these GPX gene symptoms? Check all that apply.*

Early graying or white hairErratic moodsChronic fatigueMemory problemsIrritabilityAggressionNone of the above
BASIC SYMPTOMS: Indicate if you experience any of these symptoms. Check all that apply.*

I breathe air and drink water (this gene is dysfunctional in almost all of us)I’m sensitive to chemicalsI developed gray hair earlyI have a chronic condition such as asthma, IBD, autoimmune disease, diabetes, eczema, psoriasisI have a neurological disorder that results in symptoms such as tics, tremors, seizures, or problems with gait (walking)
GST/GPX Gene Basic Symptom Score*
Basic Symptom scoring for the GST/GPX Gene:

0: Gene is functioning well

1: Gene needs attention but other genes may be the issue

2: Gene is mutated and not working at its optimal

3-5: Gene is definitely mutated and not functioning properly
DEEP DIVE SYMPTOMS: Indicate if you experience any of these symptoms. Check all that apply.*

I'm sensitive to chemicals and smellsI feel way better after taking a sauna or sweating heavilyIt's easy for me to gain weight even though I eat rightCancer runs in my family.I noticed gray or white hairs coming in when I get stressedI have early graying of my hairI have high blood pressureI just got done fighting an infectionI tend to be chronically stressed outI have an autoimmune diseaseI have chronic inflammationI have asthma or difficulty breathing. I often feel like I can't get enough airI generally feel tired and “toxic”None of the above
GST/GPX Gene Deep Dive Symptom Score*
Deep Dive Symptom scoring for the GST/GPX Gene:

0: Gene is functioning well

1-4: Gene needs attention but other genes may be the issue

5-7: Gene is mutated and not working at its optimal

8+: Gene is definitely mutated and not functioning properly. If other high scoring gene are present, they will be affecting this one most likely
Part 5 of 8: COMT SLOW Gene

These series of questions will look at the COMT gene which is associated with dopamine. There are variations of this gene mutation: the SLOW or FAST type.

The SLOW type has too much dopamine sitting in the brain
Do you experience any of these COMT SLOW gene symptoms? Check all that apply.*

Trouble winding downSleep challengesWorkaholismDifficulties metabolizing estrogenNone of the above
BASIC SYMPTOMS: Indicate if you have any of these COMT SLOW gene symptoms. Check all that apply.*

I get headachesI find falling asleep a challengeI easily become anxious or irritableI suffer from PMSI am sensitive to painNone of the above
COMT SLOW Gene Basic Symptom Score*
Basic Symptom scoring for the COMT SLOW Gene:

0: Gene is functioning well

1: Gene needs attention but other genes may be the issue

2: Gene is mutated and not working at its optimal

3-5: Gene is definitely mutated and not functioning properly
DEEP DIVE SYMPTOMS: Indicate if you have any of these COMT SLOW gene symptoms. Check all that apply*

I feel more irritable after eating a high protein diet (GAPS, paleo)I'm easily irritated, and it takes me a long time to calm downI routinely have (or used to have) PMSI'm a very happy, enthusiastic person - but it's easy to irritate meI'm not very patientI've always been able to focus and study for long hoursI've struggled with falling asleep since I was a child.My doctor put me on birth control pills to control my acne or heavy bleedingI have (or have had) uterine fibroidsCaffeine does wake me up, but I have to be careful not to drink too much or I get irritableI don't like taking risks. I'm pretty cautiousNone of the above
COMT SLOW Gene Deep Dive Symptom Score*
Deep Dive Symptom scoring for the COMT SLOW Gene:

0: Gene is functioning well

1-4: Gene needs attention but other genes may be the issue

5-7: Gene is mutated and not working at its optimal

8+: Gene is definitely mutated and not functioning properly. If other high scoring gene are present, they will be affecting this one most likely
Additional Symptoms. Check all that apply:*

I've always been able to focus and study for long hoursI enjoy traveling exploringI tend to be a workaholicWhen I get stressed, it takes me a long time to calm downI tend to work hard for weeks, then crash and need to take a long break to rechargeI get anxious and panicky easilyI find that caffeine often increases my stressI'm easily irritated. I wake up on the wrong side of the bed oftenI have strong bonesIt takes me a long time to fall asleepMy skin glows and people compliment me on itI usually get PMSI experience heavy menstrual bleedingI have or have had uterine fibroidsI'm sensitive to pain compared to othersEating a higher protein diet makes me feel more irritableI do poorly with CNS stimulant medications such as Ritalin and AdderallI do better with CNS calming medications such as IntunivNone of the above
COMT FAST Gene

These series of questions will look at the COMT gene which is associated with dopamine. There are variations of this gene mutation: the SLOW or FAST type.

The FAST type has too little dopamine sitting in the brain
Do you experience any of these COMT FAST gene symptoms? Check all that apply.*

Trouble revving up, difficulty maintaining focus; distractibility, weak memory, tendency toward depressionAddictive disorders: drugs, alcohol, gambling, sugar, etcDepressionLearning disabilityADHDNone of the above
BASIC SYMPTOMS: Indicate if you have any of these COMT FAST gene symptoms. Check all that apply.*

I struggle with attention and focusI’m easily addicted to substances or activities: shopping, gaming, smoking, alcohol/drugs, social media, sugarI’m prone to feelings of depressionI often lack motivationI fell an initial happy rush after eating lots of carbs or starchy foods, but feelings of depression return quite quicklyNone of the above
COMT FAST Gene Basic Symptom Score*
Basic Symptom scoring for the COMT FAST Gene:

0: Gene is functioning well

1: Gene needs attention but other genes may be the issue

2: Gene is mutated and not working at its optimal

3-5: Gene is definitely mutated and not functioning properly
DEEP DIVE SYMPTOMS: Indicate if you have any of these COMT FAST gene symptoms. Check all that apply*

I have difficulty paying attentionI get depressed quite oftenWhen I get stressed out, I can calm down quicklyI tend to be calm most the time, but I don't always like to beI'm a risk taker. I enjoy pulling stunts, because I feel awesome afterwardI'm the class clown. I love it when I make people laughI find myself fidgeting and moving constantlyI sometimes pinch myself so hard that it hurtsI have a hard time getting going in the morningI find that I can easily get addicted to things or activities: video games, social media, smoking, drinking, shopping, drugs, gambling, sugarI'm not very interested in sexWhen it's bedtime, my head hits the pillow and I'm out like a lightCaffeine helps me focus and pay attentionI crave high fat, high sugar foods, and they do make me feel better - only for a bit.None of the above
COMT FAST Gene Deep Dive Symptom Score*
Deep Dive Symptom scoring for the COMT FAST Gene:

0: Gene is functioning well

1-4: Gene needs attention but other genes may be the issue

5-7: Gene is mutated and not working at its optimal

8+: Gene is definitely mutated and not functioning properly. If other high scoring gene are present, they will be affecting this one most likely
Additional Symptoms. Check all that apply.*

I have a difficult time paying attention. I'm a poster child for ADHDI tend to go with the flowI'm not a workaholicWhen I get stressed I recover quickly and move onI fall asleep quicklyI need caffeineEating a higher protein diet makes me feel greatI tend to be more depressed than enthusiastic and have been for yearsI'm just not that excited about thingsI don't get PMSI have weaker bonesI'm very tolerant of pain compared to othersI do better with CNS stimulant medications such as Ritalin or AdderallI do worse with CNS calming medications such as IntunivNone of the above
Part 6 of 8: MAOA SLOW Gene

These series of questions will look at the MAOA gene which is associated with serotonin. There are variations of this gene mutation: the SLOW or FAST type.

The SLOW type has too much serotonin sitting in the brain
Do you experience any of these MAOA SLOW gene symptoms? Check all that apply.*

Difficulty falling asleepOveractive startle reflexHeadachesIrritabilityMood swingsProlonged anxietyRage and/or aggressive behaviorTrouble relaxing or powering downNone of the above
BASIC SYMPTOMS: Indicate if you have any of these MAOA SLOW gene symptoms. Check all that apply.*

I am easily stressed, panicked, or made anxiousI find it hard to calm down after becoming stressed or irritatedI enjoy cheese, wine, and/or chocolate but tend to feel irritable or “off” after I eat themI’m plagued by migraines or headachesI have difficulty falling asleep; but when I do, I tend to stay asleepNone of the above
MAOA SLOW Gene Basic Symptom Score*
Basic Symptom scoring for the MAOA SLOW Gene:

0: Gene is functioning well

1: Gene needs attention but other genes may be the issue

2: Gene is mutated and not working at its optimal

3-5: Gene is definitely mutated and not functioning properly
DEEP DIVE SYMPTOMS: Indicate if you have any of these MAOA SLOW gene symptoms. Check all that apply*

I tend to be rather aggressiveIt takes me a while to slow downI can focus for a long timeWhen I drink alcohol, I've become an angry drunkI'm not drawn to carbs, and I feel less irritable when I don't eat many of themI'm more irritable and angry when I eat cheese and/or chocolate or drink wineIt takes me a while to fall asleepWhen I do fall asleep, I tend to stay asleep through the nightMy doctor put me on an SSRI for depression, and I got very irritable from itMelatonin doesn't work well for me. it makes me feel more awake and irritableCaffeine tends to make me irritableLithium helps my mood5 - HTP makes me feel anxious and irritableInositol over stimulates meI'm self-confidentI'm a manNone of the above
MAOA SLOW Gene Deep Dive Symptom Score*
Deep Dive Symptom scoring for the MAOA SLOW Gene:

0: Gene is functioning well

1-4: Gene needs attention but other genes may be the issue

5-7: Gene is mutated and not working at its optimal

8+: Gene is definitely mutated and not functioning properly. If other high scoring gene are present, they will be affecting this one most likely
MAOA FAST Gene

These series of questions will look at the MAOA gene which is associated with serotonin. There are variations of this gene mutation: the SLOW or FAST type.

The FAST type has too little serotonin sitting in the brain
Do you experience any of these MAOA FAST gene symptoms? Check all that apply.*

Alcoholism and/or other addictionsADHDCarb and sugar cravingsDepressionDifficulty staying asleepFatigueNone of the above
BASIC SYMPTOMS: Indicate if you have any of these MAOA FAST gene symptoms. Check all that apply.*

I fall asleep quickly but wake up earlier than I’d preferI’m prone to depression and a lack of desireI find that chocolate gives me a great mood liftI tend toward smoking or alcohol addiction (or excessive use)I achieve a better mood after eating carbs, but that improved mood does not help my focus or attentionNone of the above
MAOA FAST Gene Basic Symptom Score*
Basic Symptom scoring for the MAOA FAST Gene:

0: Gene is functioning well

1: Gene needs attention but other genes may be the issue

2: Gene is mutated and not working at its optimal

3-5: Gene is definitely mutated and not functioning properly
DEEP DIVE SYMPTOMS: Indicate if you have any of these MAOA SLOW gene symptoms. Check all that apply*

Since I was a kid, I've had a very hard time focusing and paying attentionI crave cheese, wine, and chocolate, and I feel better after I consume themI crave carbohydrates, and they make me feel less depressedI fall asleep quite well, but I tend not to be able to sleep through the night. I need a snack to fall back asleepI have an autoimmune disease, such as Graves disease, Hashimoto's thyroiditis, multiple sclerosis, or active celiacI'm chronically inflamedWinters in prolonged Darkness affect my mood. I've been told I have seasonal affective disorderI love exercising. It helps my moodI'm a womanI'm a worrierI tend to be depressed and anxiousI get a bit obsessive about thingsI have fibromyalgia, constipation, or irritable bowel syndromeMelatonin works quite well to help me sleepInositol improves my mood5 - HTP improves my moodLithium makes me feel more depressedMy doctor put me on an SSRI, and it did helpNone of the above
MAOA FAST Gene Deep Dive Score Symptom Score*
Deep Dive Symptom scoring for the MAOA FAST Gene:

0: Gene is functioning well

1-4: Gene needs attention but other genes may be the issue

5-7: Gene is mutated and not working at its optimal

8+: Gene is definitely mutated and not functioning properly. If other high scoring gene are present, they will be affecting this one most likely
Part 7 of 8: MTHFR Gene

These series of questions will look at the MTHFR gene which is associated with methylation and your body and brain's ability to absorb critical and essential B-vitamins.
Do you experience any of these MTHFR gene symptoms? Check all that apply.*

AnxietyBrain fogChemical sensitivityDepressionIrritabilityHair-trigger temperGene mutation runs in familiesNone of the above
BASIC SYMPTOMS: Indicate if you have any of these MTHFR gene symptoms. Check all that apply.*

I suffer from headachesI sweat easily and profusely when exercisingI eat enriched foods with folic acidI struggle with depressionI have cold hands and feetNone of the above
MTHFR Basic Symptom Score*
Basic Symptom scoring for the MTHFR Gene:

0: Gene is functioning well

1: Gene needs attention but other genes may be the issue

2: Gene is mutated and not working at its optimal

3-5: Gene is definitely mutated and not functioning properly
DEEP DIVE SYMPTOMS: Indicate if you have any of these MTHFR gene symptoms. Check all that apply*

I get shortness of breath or become red in the face after exercisingAt times, I get exercise-induced asthmaMy mood's often fluctuate between irritability and depressionI can't easily tolerate alcohol of any typeI generally feel tired and “toxic”I don't eat leafy green vegetables everydayI tend to be able to focus and concentrate quite well, when I'm not mad or sadI have difficulty falling asleep at timesI've had laughing gas (nitrous oxide) at the dentist or the doctor's office and it made me feel horrible, strong side effectsWhen I get irritated, it takes me quite some time to calm downThere are some days I push it and take risks, but that's usually not my styleNone of the above
MTHFR Deep Dive Symptom Score*
Deep Dive Symptom scoring for the MTHFR Gene:

0: Gene is functioning well

1-4: Gene needs attention but other genes may be the issue

5-7: Gene is mutated and not working at its optimal

8+: Gene is definitely mutated and not functioning properly. If other high scoring gene are present, they will be affecting this one most likely
Additional Symptoms. Check all that apply.*

I'm hypothyroidMy white blood count has been on the low end of the normal range most of my lifeI had to have IVF or significant interventions in order to become pregnant and go to full termOne or more of my children are on the autism spectrumOne or more of my children have Down syndromeMy doctor say I don't tolerate medications such as methotrexate, 5 - fluorouracil, or phenytoin as well as other patientsI get menstrual cramping and have clots in my menstrual fluidMy homocysteine levels are routinely High - above 12 micromoles per literMy folate and/or vitamin B12 levels are elevatedNone of the above
Part 8 of 8: NOS3 Gene

These series of questions will look at the NOS3 gene which is associated the production of Nitric Oxide and blood platelets for optimal heart health.
Do you experience any of these NOS3 gene symptoms? Check all that apply.*

Platelets can become stickyAnginaAnxietyCold hands and feetDepressionHeart attackErectile dysfunctionHigh blood pressureMigrainesMouth-breathingSinus congestionWounds that are slow to healNone of the above
BASIC SYMPTOMS: Indicate if you have any of these NOS3 gene symptoms. Check all that apply.*

I have above normal blood pressure (>120/80)I have cold hands and feetI tend to heal slowly after an injuryI am a type 2 diabeticI am postmenopausalNone of the above
NOS3 Basic Symptom Score*
Basic Symptom scoring for the NOS3 Gene:

0: Gene is functioning well

1: Gene needs attention but other genes may be the issue

2: Gene is mutated and not working at its optimal

3-5: Gene is definitely mutated and not functioning properly
DEEP DIVE SYMPTOMS: Indicate if you have any of these MTHFR gene symptoms. Check all that apply.*

I have high blood pressureI've had a heart attackI have diabetes, type 1 or 2I have cold hands and feetI struggle with asthmaI snore, breathe through my mouth, or have sleep apneaI'm noticing that my memory is getting worseI had preeclampsia during pregnancyI have atherosclerosisI'm postmenopausalMy moods are all over the placeI don't exercise or move muchI have an autoimmune diseaseI'm chronically inflamedNone of the above
NOS3 Deep Dive Symptom Score*
Deep Dive Symptom scoring for the NOS3 Gene:

0: Gene is functioning well

1-4: Gene needs attention but other genes may be the issue

5-7: Gene is mutated and not working at its optimal

8+: Gene is definitely mutated and not functioning properly. If other high scoring gene are present, they will be affecting this one most likely
Additional Symptoms. Check all that apply.*

I have high blood pressureMany people in my family have high blood pressureHeart attacks are common in my familyI've had a heart attackI have a lot of circulation issues due to my diabetesI frequently have cold hands and feetStroke runs in my familyI was diagnosed with preeclampsia when I was pregnantHardening of the arteries runs in my familyI'm a mouth breatherNone of the above
Congratulations on finishing!

IMPORTANT NEXT STEPS BELOW.

The next step is to order a genetic test to confirm which genes are mutated. You will be redirected to our labshop after submitting this form, if you have not done your genetic test yet. Click here if it does not redirect.

There are two tests needed. The "DNA Methylation" is highly recommended to start with as it will look at the big 4 out of the 7 genes and results will arrive the fastest. OR you can complete the entire kit and have all major 7 genes tested!

Included in the test is a personal appointment where we will review the results and your intake form. After this review, we can scheduling a "Nutritional Audit" where we tailor a customized suggested diet and supplement protocol.
Should be Empty:

7 Major Gene Nutritional Symptom Questionnaire

Part 1 of 8: Daily Meals and Diet

Part 2 of 8: DAO Gene

Part 3 of 8: PEMT Gene

Part 4 of 8: GST/GPX Gene

Part 5 of 8: COMT SLOW Gene

COMT FAST Gene

Part 6 of 8: MAOA SLOW Gene

MAOA FAST Gene

Part 7 of 8: MTHFR Gene

Part 8 of 8: NOS3 Gene

Congratulations on finishing!

IMPORTANT NEXT STEPS BELOW.