• Post- Dysbiosis Questionnaire

    Post- Dysbiosis Questionnaire

    Designed for adults to help evaluate whether dysbiosis—an imbalance of gut bacteria—may be contributing to health issues.

  • This questionnaire is designed for adults and the scoring system is not as appropriate for children. It lists factors in your medical history which are known to contribute to the disruption of normal healthy gastrointestinal bacteria, and symptoms commonly found in individuals with dysbiosis related illness (Section B and C).

    Filling out and scoring this questionnaire should help you and your physician evaluate the possible role of dysbiosis in contributing to your health problems. Yet will not provide and automatic “Yes” or “No” answer.

    Note: Dysbiosis refers to the condition where the normal healthy population of beneficial bacteria in the intestines had been disrupted, leaving it open to the overgrowth of yeast, fungi, parasites and potentially harmful strains of bacteria. This intestinal imbalance in turn adversely effects other important systems via toxic stress and interfering with nutrient absorption and utilizatio

  • SECTION B — MAJOR SYMPTOMS

    * Section A- should be completed in the Pre- Dysbiosis Questionnaire

  • For each of your symptoms, enter the appropriate figure on the line following the question:

    • If this symprom does not apply to you= 0
    • If a symptom is occasional or mild = 3 points.
    • If a symptom is frequent &/or moderate = 6 points.
    • If a symptom is severe or disabling = 9 point. 

    Your Total score is recorded down below

  • Fatigue or lethargy*
  • Feeling of being drained*
  • Poor memory*
  • Feeling “spacey” or “unreal”*
  • Numbness, burning, or tingling*
  • Muscle aches*
  • Muscle weakness or paralysis*
  • Pain and/or swelling in joints*
  • Abdominal pain*
  • Constipation*
  • Diarrhea*
  • Bloating*
  • Troublesome vaginal discharge*
  • Persistent vaginal burning or itching*
  • Prostatitis*
  • Impotence*
  • Loss of sexual desire*
  • Endometriosis*
  • Cramps and/or other menstrual irregularities*
  • Premenstrual tension*
  • Spots in front of eyes*
  • Erratic vision*
  • Eczema, dermatitis, psoriasis*

  • SECTION C — OTHER SYMPTOMS

  • For each of your symptoms, enter the appropriate figure on the line following that question.

    • If the symptom does not apply to you = 0pt
    • If the symptom is occasional or mild = 1pt
    • If the symptom is frequent &/or moderately severe = 2pt
    • If the symptom is sever &/or disabling = 3pt

    Your Total score is recorded down below

  • Drowsiness*
  • Irritability*
  • Poor coordination*
  • Inability to concentrate*
  • Frequent mood swings*
  • Headache*
  • Dizziness or loss of balance*
  • Pressure above ears / head swelling / tingling*
  • Itching*
  • Other rashes*
  • Heartburn*
  • Indigestion*
  • Belching & intestinal gas*
  • Mucus in stools*
  • Hemorrhoids*
  • Dry mouth*
  • Rash or blisters in mouth*
  • Bad breath*
  • Nasal congestion or discharge*
  • Joint swelling or arthritis*
  • Postnasal drip*
  • Nasal itching*
  • Sore or dry throat*
  • Cough*
  • Pain or tightness in chest*
  • Wheezing or shortness of breath*
  • Urgency or urinary frequency*
  • Burning on urination*
  • Failing vision*
  • Burning or tearing of eyes*
  • Recurrent infection or fluid in ears*
  • Ear pain or hearing loss*

  • The grand total score will help you and your physician decide if your health problems are dysbiosis related.

    Please discuss the result of this post- dysbiosis questionnaire with your physician.

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