Digestive Health Evaluation
Stomach Function
1. Indigestion, taste or burp food hours after eating
No
Mild
Moderate
Severe
2. Low iron/anemia
No
Yes
3. Use antacids or take medications for digestion
Never
Once or twice weekly
Three to five times weekly
Daily
Stomach Function %
Gastrointestinal Inflammation
4. Feel a sense of nausea when you eat or before you eat
No
Mild
Moderate
Severe
5. Stomach pain relieved by eating food, drinking carbo-nated beverages, milk, or taking antacids
No
Mild
Moderate
Severe
6. Indigestion after eating may be 30 to 90 minutes after eating
No
Mild
Moderate
Severe
7. Muscle twitching
No
Mild
Moderate
Severe
Gastrointestinal Inflammation %
Small Intestines and Pancreas
8. Pain under your rib cage on your left side
No
Mild
Moderate
Severe
9. Indigestion is delayed, occurring 2-4 hours after eating a meal
No
Mild
Moderate
Severe
10. The consistency or form of your stool changes (e.g., from narrow to loose) within the course of a day
No
Mild
Moderate
Severe
11. Excessive odor with bowel movements
No
Mild
Moderate
Severe
12. Undigested food in your bowel movements
No
Mild
Moderate
Severe
13. Diarrhea or frequently loose stools
No
Mild
Moderate
Severe
Small Intestines and Pancreas %
Large intestines
14. Discomfort, pain or cramps in your lower abdominal area
No
Mild
Moderate
Severe
15. Eating raw fruits and vegetables causes gas, bloating, and pain in lower abdomen
No
Mild
Moderate
Severe
16. Anal itch
No
Mild
Moderate
Severe
Large intestines %
Gallbladder
17. Bowel movements alternate from normal to clay colored
No
Mild
Moderate
Severe
18. Sporadic pains in the middle of the upper abdomen, or just below the ribs on the right side
No
Mild
Moderate
Severe
19. History of gallstones or attacks, had gallbladder removed (if yes answer severe)
No
Mild
Moderate
Severe
Gallbladder %
Nutritional Deficiency
20. Muscle cramping
No
Mild
Moderate
Severe
21. Ridges on nails, longitudinal
No
Mild
Moderate
Severe
22. Gingivitis, gums bleeding
No
Mild
Moderate
Severe
23. Anorexia or bulimia
Never
Within last 5 years
Within last 2-5 years
Currently or within last 2 years
24. Cracking/peeling/brittle/splitting fingernails or fingertips (i.e. hang nails)
No
Mild
Moderate
Severe
25. Small bumps on back of upper arms and/or thighs
No
Mild
Moderate
Severe
Nutritional Deficiency %
Immune Function
26. Suffer from eczema, psoriasis, lupus, MS, RA, Crohn’s or any other autoimmune condition
No
Yes
27. Recurrent thrush or fungal infections
No
Yes
28. Used intravenous antibiotics to clear infection or taken antibiotics for more than 30 days continuously
No
Yes
29. Frequency of sinus, ear, yeast, kidney, bladder, skin and lung infections
None
2 to 3 times per year
4 to 5 times per year
6 or more times per year
30. Frequent colds or flu
None
2 to 3 times per year
4 to 5 times per year
6 or more times per year
31. Suffer from allergies
Never
Rarely
Occasionally
Often
Immune Function %
Digestive System Total %
Please list your top 5 complaints. If you don’t have 5 that is okay.
1
2
3
4
5
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