Name
First Name
Last Name
Email
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Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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.
Check Any That You Are Dealing With
Sub-Clinical Symptoms Including:
Headaches
Migraines
Hormone Imbalance Including:
PMS
Emotional Imbalance
Gastrointestinal Issues Including:
Abdominal bloating, cramps or painful gas
Irritable Bowel Syndrome
Ulcerative Colitis
Crohn's Disease and other intestinal disorders
Respiratory Conditions Including:
Chronic Sinusitis
Asthma
Allergies
Joint Conditions Including:
Knee, Shoulder or Spine
Auto-Immune Conditions Including:
Diabetes Mellitus
Lupus
Fibromyalgia
Chronic Fatigue
Thyroid Conditions Including:
Hashimotos
Hypothyroidism
Hyperthyroidism
Developmental Conditions Including:
Autism
ADD/ADHD
Skin Conditions Including:
Eczema
Skin Rashes
Hives
Psoriasis
Pick the number that most closely fits
0 - None, 1- Mild, 2- Moderate, 3 Severe
Constipation and or diarrhea
*
None
0
1
2
Severe
3
0 is None, 3 is Severe
Abdominal pain or bloating
0
1
2
3
0 is , 3 is
Mucous or blood in stool
*
0
1
2
3
0 is , 3 is
Joint pain or swelling, arthritis
*
0
1
2
3
0 is , 3 is
Chronic or frequent fatigue or tiredness
*
0
1
2
3
0 is , 3 is
Food allergies, sensitivities or intolerances
*
0
1
2
3
0 is , 3 is
Sinus or nasal congestion
*
0
1
2
3
0 is , 3 is
Eczema, skin rashes or hives
*
0
1
2
3
0 is , 3 is
Asthmas, Hayfever or airborne allergies
*
0
1
2
3
0 is , 3 is
Confusion, poor memory or mood swings
*
0
1
2
3
0 is , 3 is
Use of NSAIDS (Aspirin, Tylenol, Motrin)
*
0
1
2
3
0 is , 3 is
History of antibiotic use
*
0
1
2
3
0 is , 3 is
Alcohol consumption makes you feel sick
*
0
1
2
3
0 is , 3 is
Gluten sensitivity or Celiac's Disease
*
0
1
2
3
0 is , 3 is
Nausea
*
0
1
2
3
0 is , 3 is
Weight Issues
*
0
1
2
3
0 is , 3 is
Submit
Should be Empty: