Health Profile - Gut Health
Please complete this health profile by answering all questions in order.
Respondent Details
Age
*
Gender
*
Male
Female
Email
*
Please enter your email address.
Height (inches)
*
Weight (pounds)
*
Pregnant?
Yes
No
N/A
Nursing?
Yes
No
N/A
Medical and Health History
Current conditions
Heart Disease
Cancer
Diabetes
High Blood Pressure
Urinary Tract Infections
Yeast/Fungal Infections
Thyroid Disease
Alcoholism/Drug Addiction
IBS/Crohn's/Colitis
Celiac Disease
Autoimmune Condition
PMS
None
Diagnosed conditions
Bipolar Disorder
Eating Disorder
Seizure Disorder
Panic Disorder/PTSD
OCD
Schizophrenia
Autism/PDD
ADD/ADHD
Alzheimer's/Dementia
Parkinson's
Kidney Disease
None
Gallbladder removed?
*
Yes
No
Antibiotic in last 6 months?
*
Yes
No
Diet, Intake, and Lifestyle
Current diet
Gluten Free
Dairy Free
Egg Free
Paleo
Ketogenic
Vegan
Vegetarian
None
Food sensitivities
Cow's Milk/Casein
Wheat/Gluten
Eggs
Soybeans
Corn
Fish
Shellfish
Tree Nuts
Peanuts
Pineapple
None
Food allergies
Cow's Milk/Casein
Wheat/Gluten
Eggs
Soybeans
Corn
Fish
Shellfish
Tree Nuts
Peanuts
Pineapple
None
Water intake
1-2 glasses/day
3-5/day
6+/day
None
Cravings
Carbohydrates
Chocolate
Sugar
Salty Foods
Alcohol
Recreational Drugs
None
International travel frequency
Never
1-3x/year
4+/year
Symptoms and Medications
GI symptoms
*
Gas
Bloating
Trouble Digesting
Heartburn/Reflux
Belching
Frequent Bowel Movements
Constipation
Diarrhea
None
Skin conditions
Eczema
Psoriasis
Dandruff
Acne
Hives
Rashes
None
Other symptoms
Depression/mood swings
Headaches/migraines
Chronic aches and pains
Get sick often
Runny nose
Sinus congestion
Excess mucus
None
Can swallow capsules?
*
Yes
No
Medications for
Blood Thinner
Blood Pressure
Cholesterol
Heartburn
Pain Relievers
None
Current prescriptions with dosage
Current supplements with dosage
Primary health concerns
*
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