Digestive questionnaire
Customer Details:
Full Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
How did you hear about us?
*
Please Select
Instagram
Word of mouth
Facebook
Threads
Please Specify
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Please mark any of the following that you eat regularly
Alcohol
Candy
chewing tobacco
fried foods
Coffee
Soft drinks
Conventional dairy
Soy products
Fast foods
Sugar & sweets
Trans fat
Gluten containing items
Do you cook meals at home from scratch?
yes
No
How many total meals do you eat at home each week?
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How many total meals do you dine out each week?
Please describe your current diet
Activity and lifestyle
How many hours a day are you inactive or sitting?
How many times do you exercise per week? And for how long?
Do you sweat when you exercise?
yes
no
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Is it heavy or minimal?
heavy
moderate
Minimal
How many hours do you sleep each night?
Do you feel rested when you wake up?
yes
no
Are you currently experiencing high levels of stress?
yes
no
Rate the amount of stress on a scale of 1-10
1 being minimal, 10 being tremendous
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Part 2
Part 2 of this Questionnaire will help a person identify which parts of the digestive tract arecausing the most problems or symptoms.Please enter in the number that best describes the severity of the symptoms listed below. If youdo not know the answer then leave it blank. Then add up the totals of the numbers and decide which areas need the most attention. 0 = not present at all 1 = Sometimes occurs with mild severity 2 = Occurs often with moderate severity 3 = Severe and always occurs
Section 1: low stomach acid
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Rows
0- Never/almost never have the symptom/I’m not sure
1- sometimes occurs with mild severity
2-often occurs with moderate severity
3- severe and always occurs
Bloating after eating
Poor appetite
Stomach upsets easily
Constipation
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
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Calculation
Section 2. IMPROPER FUNCTION OF THE PANCREAS/SMALL INTESTINE
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Rows
0- Never/almost never have the symptom/I’m not sure
1- sometimes occurs with mild severity
2-often occurs with moderate severity
3- severe and always occurs
Have a difficult time 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 & diarrhea
Flatulence
Autoimmune condition(s) present
Tiredness after eating
shiny stool
3 or more large bowel movements per day
Chronic stomach pain on left side below ribs
Excessive smelly stool
Nausea
Undigested food in stool
Gallbladder disease or history of gallstones
Acid reflux/heart burn/gerd
Diabetes
osteoporosis
Alcoholism
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Calculation
Section 3. ACID REFLUX
*
Rows
0- Never/almost never have the symptom/I’m not sure
1- sometimes occurs with mild severity
2-often occurs with moderate severity
3- severe and always occurs
Sour taste in the mouth after eating
Coughing in the middle of the night
heartburn
Have a hard time swallowing food and liquids
Constant burping, especially after meals
Regurgitating undigested food in mouth
Burning in the stomach after eating citrus
Calculation
Section 4. Too much stomach acid or possible ulcers
*
Rows
0- Never/almost never have the symptom/I’m not sure
1- sometimes occurs with mild severity
2-often occurs with moderate severity
3- severe and always occurs
Previous use of aspirin or NSAIDS
Black stool (and are not taking iron supps)
History of previous ulcers
family history of ulcers or gastritis
Stomach pain relieved by drinking dairy
Carbonated drinks temporarily relieve pain
Frequent indigestion
Frequent burping and boating
Regular butterflies in the stomach feeling
Constant abdominal pain
Antacids required for heart burn and/or acid reflux
Pain in the stomach before meals
General stomach pain
Pain in the stomach occurs when stressed or upset
Calculation
Section 5. Gallbladder and liver function
Rows
0- Never/almost never have the symptom/I’m not sure
1- sometimes occurs with mild severity
2-often occurs with moderate severity
3- severe and always occurs
Have a hard time gaining weight
Multiple food allergies
have a hard time gaining weight
Skin issues or acne
Dry skin
dry or brittle hair
Hard stool
Tiredness after eating
Halitosis or bad breathe
Yellowish tint in the white of eyes
Grayish colored skin
Sour taste in mouth
constipation
not having a daily bowel movement
Pain felt/radiating on 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 to greasy foods
Pain in the right side under the rib cage
Have had jaundice or hepatitis (no=0, more then 2 years ago=1, current =2, chronic =3)
Blood in the stool (red color) (no=0, more then 2 years ago=1, current =2, chronic =3)
High blood cholesterol and low HDL (no=0, unknown = blank, yes = 2)
Cholesterol above 200 (no=0, unknown = blank, yes = 2)
Triglyceride level above 115 (no=0, unknown = blank, yes = 2)
Calculation
Section 6. Dysbiosis or bacterial overgrowth
*
Rows
0- Never/almost never have the symptom/I’m not sure
1- sometimes occurs with mild severity
2-often occurs with moderate severity
3- severe and always occurs
Bloating
have brain fog
have bad breathe
Take antacids (ex: tums)
Have food sensitivities/intolerances
Have severe stress
Have acid reflux or heartburn
Vitamin d deficiency
Arthritis or fibromyalgia I
Taken antibiotics more then twice in the past year
Have trouble digesting beans and fiber
Have trouble digesting carbs
Depressed or anxious all the time
Have sinus congestion
Have constipation
Have chronic diarrhea
Often get stomach bugs
Have cramps after you eat
Have mucus or blood in stool
Diagnosed with an autoimmune disease or condition
Calculation
Section 7. Possible small intestine bacterial overgrowth
*
Rows
0- Never/almost never have the symptom/I’m not sure
1- sometimes occurs with mild severity
2-often occurs with moderate severity
3- severe and always occurs
Currently taking antacids or proton pump inhibiitors for heartburn or GERD
Excessive flatulence or gas
Abdominal pain
Fibromyalgia
Intolerance to probiotic supplements and prebiotic fibers
Abdominal bloating and distension, especiallywith carbohydrates such as sugar & fiber
Diarrhea
irritable bowel syndrome (IBS)
Restless leg syndrome
Scored 9 or more on low stomach acid section
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Calculation
Section 8. Low digestive enzyme production
*
Rows
0- Never/almost never have the symptom/I’m not sure
1- sometimes occurs with mild severity
2-often occurs with moderate severity
3- severe and always occurs
Take antacids or acid blocking meds
Have glucose intolerance
Have food sensitivities/intolerances
Bruise easily (can also be low Vit. K)
B12 deficiency
Ankles swell
do not have daily bowel movements
Have constipation
foul smelling stool
Have bad breathe
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
Reoccurring headaches
Depression, in any form
Fatigue in spite of a good diet and regular sleep
Inability to gain muscle despite weight training
Often eat in a rush
Chew your food properly
Calculation
Section 9. Leaky gut or intestinal permeability
*
Rows
0- Never/almost never have the symptom/I’m not sure
1- sometimes occurs with mild severity
2-often occurs with moderate severity
3- severe and always occurs
Chronic sinus or nasal congestion
Headaches or migraines
history of antibiotic use
Chronic and frequent inflammation
Chronic and frequent fatigue or tiredness
Mucus or blood in stool
Constipation and or diarrhea
Eczema, skin conditions or hives
Ulcerative colitis, Chrons disease or Celiac disease
Use of nonsteroidal anti-inflammatory drug's(Aspirin, Tylenol, Motrin, Ibuprofen)
Tiredness after eating
Halitosis or bad breathe
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
Calculation
Section 10. Possible gluten sensitivity
*
Rows
0- Never/almost never have the symptom/I’m not sure
1- sometimes occurs with mild severity
2-often occurs with moderate severity
3- severe and always occurs
Brain fog
Fibromyalgia
Achy joints or chronic joint pain
Memory issues
Headaches or migraines
fatigue
Gut infections easily
Menstrual problems
Infertility
thyroid problems
Anemic or iron deficiency anemia
Have a hard time losing weight
Nausea
constipation or diarrhea
Bloating And or gas
Osteoporosis or osteopena
Family history of cancer
family history of arthritis
History of auto immune disease
Family history of celiac disease
Calculation
Section 11. Large intestine or colon problems
*
Rows
0- Never/almost never have the symptom/I’m not sure
1- sometimes occurs with mild severity
2-often occurs with moderate severity
3- severe and always occurs
Family history of inflammatory bowel disease (IBD)
Blood or pus in the stool
Recurrent stomach pain
Failing vision
History of antibiotic use
Constipation
vaginal yeast infections or oral thrush
Bladder and kidney infections
Frequent and reoccurring infections
Seasonal or reoccurring diarrhea
Alternating diarrhea and constipation
Toe and fingernail fungus
Abdominal cramping
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Calculation
Submit
Should be Empty: