Wellness Evaluation

Wellness Evaluation
First Name*
Last Name*
Phone Number*
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Email*
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Which office do you regularly attend?
WELLNESS EVALUATION

In medicine today, leaky gut aka intestinal permeability, isn’t typically diagnosed. However that doesn’t mean it’s not affecting your health. Many health issues related to gut health go undiagnosed, misdiagnosed, or are ignored by traditional medicine. Please complete this evaluation to help our doctors determine how we can help your condition.

Let’s get started!
Check all that apply to you:
Sub-Clinical Symptoms including:

HeadachesMigraines
Hormone Imbalance Including:

PMSEmotional Imbalance
Gastrointestinal Issues Including:

Abdominal bloating, cramps, or painful gasIrritable Bowel SyndromeUlcerative ColitisCrohn’s Disease and other intestinal disorders
Respiratory Conditions Including:

Chronic SinusitisAsthmaAllergies
Joint Conditions Including:

Knee, Shoulder, or Spine
Autoimmune Conditions Including:

Diabetes MellitusLupusRheumatoid ArthritisFibromyalgiaChronic Fatigue
Thyroid Conditions Including:

Hashimoto'sHypothyroidismHyperthyroidism
Developmental and Social Concerns Including:

Autism / Asperger'sADD / ADHD
Skin Conditions Including:

EczemaSkin RashesHives
Do you suffer with any of the following? Circle the number that most closely fits.
Constipation and/or Diarrhea*

0

1

2

3

0 is None, 3 is Severe
Abdominal Pain or Bloating*

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0 is None, 3 is Severe
Mucous or Blood in Stool*

0

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0 is None, 3 is Severe
Joint Pain or Swelling, Arthritis*

0

1

2

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0 is None, 3 is Severe
Chronic or Frequent Fatigue or Tiredness*

0

1

2

3

0 is None, 3 is Severe
Food Allergies, Sensitivities, or Intolerances*

0

1

2

3

0 is None, 3 is Severe
Sinus or Nasal Congestion*

0

1

2

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0 is None, 3 is Severe
Chronic or Frequent Inflammations*

0

1

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0 is None, 3 is Severe
Eczema, Skin Rashes, or Hives (Urticaria)*

0

1

2

3

0 is None, 3 is Severe
Asthma, Hay Fever, or Airborne Allergies*

0

1

2

3

0 is None, 3 is Severe
Confusion, Poor Memory, or Mood Swings*

0

1

2

3

0 is None, 3 is Severe
Use of NSAIDS (Aspirin, Tylenol, Motrin)*

0

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2

3

0 is None, 3 is Severe
History of Antibiotic Use*

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0 is None, 3 is Severe
Alcohol Consumptions Makes You Feel Sick*

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0 is None, 3 is Severe
Gluten Sensitivity or Celiac Disease*

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0 is None, 3 is Severe
Nausea*

0

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0 is None, 3 is Severe
Weight Issues*

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0 is None, 3 is Severe
Your Total (Adding up all the numbers in this section)
Should be Empty: