Digestive Questionnaire Date MM DD YYYY Contact Information Name * First Name Last Name Email * Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Diet and Nutrition Do you drink alcohol? Yes No If so, how many drinks per day? If so, how many drinks per week? Do you consume any of the following regularly? Candy Soft Drinks Sugar & Sweets Chewing Tobacco Conventional Dairy Trans Fats Fried Foods Soy Products Gluten-containing Products Fast Food Do you drink coffee? Yes No If so, how many cups per day? Do you cook meals at home from scratch? Yes No 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 you inactive or sitting? How many times do you exercise per week? For how long? Do you sweat when you exercise? Yes No Is it heavy or minimal? How many hours of sleep do you get each night? Do you feel rested when you wake up in the morning? Yes No Are you currently experiencing high levels of stress? Yes No Rank your amount of stress from 1-10, with 1 being none and 10 being tremendous amounts. 1 2 3 4 5 6 7 8 9 10 Symptoms Please enter the number that best describes the severity of the symptoms listed below. If you do not know the answer, please leave it blank. 0 - not present at all 1 - sometimes occurs with mild severity 2 - occurs often with moderate severity 3 - severe and always occurs Section 1 - Stomach Acid Bloating after eating Food allergies Poor appetite Low iron or anemic Stomach upsets easily Burping Constipation Nausea after taking supplements or eating Rosacea or acne Tested positive for candida or parasites Fullness for extended times after meals Take antacids TOTAL Section 2 - Pancreas/Small Intestine Have a difficult time gaining weight Tiredness after eating Multiple food allergies Shiny stool Skin issues or acne (not around jawline) Three or more large bowel movements, per day Dry skin Chronic stomach pain (specifically on the left side, below your ribs) Dry or brittle hair Excessively smelly stools Poor appetite Nausea Stool poorly formed Undigested food in stool Slimy stool or mucus in stool Gall bladder disease or history of gallstones Vegetables and fiber cause constipation Acid reflux/heartburn/GERD Diarrhea Diabetes Alternating constipation and diarrhea Osteoporosis Flatulence Alcoholism Autoimmune condition(s) present TOTAL Section 3 - Acid Reflux Sourness taste in mouth regularly Constant burping, especially after meals Coughing in the middle of the night Regurgitating undigested food into the mouth Heartburn Burning in the stomach when eating citrus Having a hard time swallowing food and liquids TOTAL Section 4 - Stomach 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 History of using aspirin or NSAIDS Black stool (and are not taking iron supplements) History of ulcer(s) Family history of ulcers or gastritis Stomach pain relieved by drinking dairy Carbonated drinks temporarily relieve pain Frequent indigestion Pain in stomach when stressed or upset TOTAL Section 5 - Gallbladder and Liver Have a hard time gaining weight Tiredness after eating Multiple food allergies Halitosis or bad breath Skin issues or acne Yellowish tint in the white of the eyes Dry skin Grayish colored skin Dry or brittle hair Sour taste in the mouth Hard stool Constplation Not having a daily bowel movement Foul smelling stool Light colored stool Water retention Painful bowel movements Have had jaundice or hepatitis Migraines or headaches after eating Intolerance to greasy foods High blood cholesterol Low HDL Blood in the stool (reddish color) Cholesterol above 200 TOTAL Section 6 - Dysbiosis or Bacterial Overgrowth Bloating Have trouble digesting beans and fiber Brain fog Have trouble digesting carbohydrates Have bad breath Depressed or anxious all the time Take antacids (TUMS) Have sinus congestion Have food sensitivities/intolerances Have constipation Have severe stress Have chronic diarrhea Often get stomach bugs Have a vitamin D deficiency Have cramps after you eat Have arthritis or fibromyalgia Have mucus or blood in your stool Taken antibiotics more than twice in the past year Diagnosed with an autoimmune disease or condition TOTAL Section 7 - Small Intestinal Health Currently taking antacids or proton pump inhibitors for heartburn or GERD Abdominal bloating and distension, especially with carbohydrates such as sugar and fiber Excessive gas/flatulence Diarrhea Abdominal pain Irritable bowel syndrome (IBS) Fibromyalgia Restless Leg Syndrome Intolerance to probiotic supplements TOTAL Section 8 - Enzyme Production Belching or flatulence after eating Abdominal bloating or swelling Undigested food in the stool 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 Take antacids or acid blocking meds Have glucose intolerance Have food sensitivities/intolerances Bruise easily (can also be low vitamin k) Have a B12 deficiency Ankles swell Have constipation Have foul smelling foods Have bad breath Fullness after a meal Indigestion after meals Bloating after meals TOTAL Section 9 - Gut and Intestinal Health Chronic sinus or nasal congestion Tiredness after eating Headaches or migraines Halitosis or bad breath History of antibiotic abuse Asthma, hay fever, or airborne allergies Chronic and frequent inflammation Food allergy or food intolerances Chronic or frequent fatigue or tiredness Joint pain/swelling/arthritis Mucus or blood in the stool Abdominal pain or bloating Constipation and/or diarrhea Confusion/poor memory/mood swings Eczema, skin conditions, or hives Light colored stool Ulcerative colitis, Chrons disease or Celiac disease Alcohol consumption or alcohol makes you feel sick Use of non-steroidal anti-inflammatory drugs (Asprin, Tylenol, Motrin, Ibuprofen) TOTAL Section 10 - Gluten Sensitivity Brain fog Anemic or iron deficiency Fibromyalgia Have a hard time losing weight Achy joints or chronic joint pain Nausea or memory issues Constipation and/or diarrhea Headaches or migraines Bloating and/or gas Fatigue Osteoporosis or osteopenia Get infections easily Personal or family history of cancer Menstrual problems Personal or family history of arthritis Infertility Personal or family history of autoimmune disease Thyroid problems Personal or family history of celiac disease Total Section 11 - Large Intestine Health Personal or family history of inflammatory bowel disease Bladder and/or kidney infections Blood in the stool Frequent and recurrent infections Recurrent stomach pain Seasonal or recurring diarrhea Failing vision Alternating diarrhea and constipation History of antibiotic use Toe and/or fingernail fungus Constipation Abdominal cramping Vaginal yeast infections or oral thrush TOTAL Thank you! I will be in touch soon.