Gut Health Questionnaire

Your Gut: The Command Center of Your Health

Your gut isn’t just about digestion—it’s the epicenter of your immune system, metabolism, mental health, and energy levels. When your gut is thriving, so are you. When it’s compromised, it can show up as bloating, fatigue, skin issues, weight gain, or even brain fog.

This comprehensive assessment is designed to help you uncover what’s happening in your digestive system. Is your microbiome balanced? Are you struggling with leaky gut, low stomach acid, bacterial overgrowth, or sluggish detox pathways? The answers are here.

Your gut is the foundation of your health. Let’s uncover the root cause of your symptoms so you can restore balance, reclaim energy, and feel your best from the inside out.

Name

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Email

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PART 1
Is aimed at assessing lifestyle and gastrointestinal health. The answers can help a person identify problem areas and target treatment accordingly.

DIET AND NUTRITION - Please mark any of the following that you eat regularly.

Do you cook meals at home from scratch?

How many total meals do you eat at home each week?

How many meals per week do you dine out?

Please describe your current diet:

ACTIVITY AND LIFESTYLE

How many hours a day are your inactive or sitting?

How many times do you exercise per week?

For how long?

Do you sweat when you exercise?

It is heavy or minimal?

How many hours of sleep do you get each night?

Do you feel rested when you wake up in the morning?

Are you currently experiencing high levels of stress?

Rank the amount of stress from 1-10 with 1 being none and 10 being tremendous amounts.

PART 2

Part 2 of this Questionnaire will help a person identify which parts of the digestive tract are causing the most problems or symptoms.

Please enter in the number that best describes the severity of the symptoms listed below. If you do 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

Bloating after eating

Poor appetite

Stomach upsets easily

Constipation

Rosacea or 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

TOTAL

Section 2. IMPROPER FUNCTION OF THE PANCREAS/SMALL INTESTINE

Have a difficult time gaining weight

Multiple food allergies

Skin issues or acne (not around jawline)

Dry Skin

Dry or brittle hair

Poor appetite

Stool poorly formed

Slimy stool or mucus in stool

Vegetables and fiber cause constipation

Diarrhea

Alternating constipation and diarrhea

Flatulence

Autoimmune condition(s) present

Tiredness after eating

Shinny stool

3 or more large bowl movements per day

Chronic stomach pain on the left side below ribs

Excessively smelly stools

Nausea

Undigested food in stool

Gallbladder disease or history of gallstones

Acid reflux/ heartburn/GERD

Diabetes

Osteoporosis

Alcoholism

TOTAL

Section 3. ACID REFLUX

Sourness tastes in mouth regularly

Coughing in the middle of the night

Heartburn

Have a hard time swallowing food & liquids

Constant burping, especially after meals

Reguritating undigested food into the mouth

Burning in the stomach when eating citrus

TOTAL

Section 4. TOO MUCH STOAMCH ACID OR POSSIBLE ULCER(S)

Previous use of aspirin or NSAIDS

Black stool (& are not taking iron supplements)

History of previous ulcer

Family history of ulcers or gastritis

Stomach pain relieved by drinking dairy

Carbonated drinks temporarily relieve pain

Frequent indigestion

Frequent burping and bloating

Regular butterflies in the stomach feeling

Constant abdominal pain

Antacids required for heartburn and/or acid reflux

Pain in the stomach before meals

General stomach pain

Pain in stomach occurs when stressed or upset

TOTAL

Section 5. GALLBLADDER AND LIVER DYSFUNCTION

Have a hard time gaining weight

Multiple food allergies

Skin issues or acne

Dry skin

Dry or brittle hair

Hard stool

Tiredness after eating

Halitosis or bad breath

Yellowish tint in the whites of the eyes

Grayish colored skin

Sour taste in the mouth

Constipation

Not having a daily bowel movement

Pain felt/radiating on the outside of leg

Pain in the big toe only

Water retention

Painful bowel movements

Have had jaundice or hepatitis (No = 0, More than 2 years ago = 1, Current =2, Chronic =3)

Blood in the stool (reddish color) (No = 0, More than 2 years ago = 1, Current =2, Chronic =3)

Triglyceride level above 115 (No = 0, Unknown = blank, Yes =2)

Foul smelling stool

Light colored stool

Migraines or headaches after eating

Intolerance to greasy foods

Pain in the right side under the rib cage

High blood cholesterol and low HDL (No = 0, Unknown = blank, Yes =2)

Cholesterol above 200 (No = 0, Unknown = blank, Yes =2)

TOTAL

Section 6. DYSBIOSIS OR BACTERIAL OVERGROWTH

Bloating

Have brain fog

Have bad breath

Take antacids (ex. TUMS)

Have food sensitives/intolerances

Have severe stress

Have acid reflux or heartburn

Have a vitamin D deficiency

Have arthritis or fibromyalgia

Taken antibiotics more than twice in the past year

Have trouble digesting beans and fiber

Have trouble digesting carbohydrates

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 your stool

Diagnosed with an autoimmune disease or condition

TOTAL

Section 7. POSSIBLE SMALL INTESTINAL BACTERIAL OVERGROWTH (SIBO)

Currently taking antacids or proton pump inhibiitors for heartburn or GERD

Excessive gas/flatulence

Abdominal pain

Fibromyalgia

Intolerance to probiotic supplements and prebiotic fibers

Abdominal bloating and distension, especially with carbohydrates such as sugar & fiber

Diarrhea

Irritable bowel syndrome (IBS)

Restless Leg syndrome

Scored 9 or more on low stomach acid section

TOTAL

Section 8. LOW DIGESTIVE ENZYME PRODUCTION

Take antacids or acid blocking meds

Have glucose intolerance

Have food sensitivities/intolerances

Bruise easily (can also be low Vit. K)

Have a B12 deficiency

Ankles swell

Have daily bowel movement

Have constipation

Have foul smelling stools

Have bad breath

Fullness after a meal

Indigestion after meals

Bloating after meals

Belching or flatulence after eating

Abdominal bloating or swelling

Undigested food in the stool

Signs of poor digestion of fatty foods

Weak, peeling or cracked fingernails

Any skin condition

Recurring 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

TOTAL

Section 9. LEAKY GUT OR INTESTINAL PERMIABILITY

Chronic sinus or nasal congestion

Headaches or migraines

History of antibiotic use

Chronic and frequent inflammation

Chronic or frequent fatigue or tiredness

Mucus or blood in the stool

Constipation and or diarrhea

Eczema, skin conditions or hives

Ulcerative colitis, Chrons disease or Celiac disease

Use of nonsteroidal anti-inflammatory drugs(Asprin, Tylenol, Motrin, Ibuprofen)

Tiredness after eating

Halitosis or bad breath

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

TOTAL

Section 10. GLUTEN SENSITIVITY

Brain fog

Fibromyalgia

Achy joints or chronic joint pain

Memory Issues

Headaches or migraines

Fatigue

Get infections easily

Menstraul problems

Infertility

Thyroid problems

Anemic or iron deficiency anemia

Have a hard time losing weight

Nausea

Constipation and or diarrhea

Bloating and or gas

Osteoporosis or osteopenia

History of family history of cancer

History of family history of arthritis

History of family history of autoimmune disease

History of family history of celiac disease

TOTAL

Section 11. LARGE INTESTINE OR COLON PROBLEMS

Family history of Inflammatory Bowel Disease

Blood or pus in the stool

Recurrent stomach pain

Failing vision

History of antibiotic use

Constipation

Vaginal yeast infections or oral thursh

Bladder and kidney infections

Frequent and recurrent infections

Seasonal or recurring diarrhea

Alternating diarrhea and constipation

Toe and fingernail fungus

Abdominal cramping

TOTAL

Gastrointestinal & Digestive Lifestyle Questionnaire