Contact Us
How to Find Us
0425 717 407
Toggle navigation
Home
About
Services
Our Clinic
Blog Posts
Resources
Questionnaires
Books
Cookbooks
Going gluten-free
Green Living
LIfestyle Advice
Testimonials
Courses
Shop
Contact
Gut Health Questionnaire
Gut Health Questionnaire
Full Name
Age
Date
E-mail address
Paragraph
Disclaimer This is a screening tool and does not constitute an exact diagnosis of your problems. Each section represents a type of gut health issue. Your answers can be another tool that will point me in the right direction to determine where your greatest opportunities for gut health improvement lie. Please be mindful that many of the questions repeat themselves in multiple sections e.g. constipation and or diarrhoea. This is because certain conditions have similar symptoms.
SECTION A: 1. A sore in your mouth that doesn’t heal
0
1
2
3
SECTION A: 2 Bleeding or swelling after you floss or brush your teeth
0
1
2
3
SECTION A: 3 Canker sores or cold sores1. A sore in your mouth that doesn’t heal
0
1
2
3
SECTION A: 4 Chronic bad breath or sour taste in the mouth
0
1
2
3
SECTION A:5 Dry mouth / poor salivation
0
1
2
3
SECTION A: 6 Fissures in your tongue or geographic tongue (red patches)
0
1
2
3
SECTION A: 7 Loose teeth or receding gums
0
1
2
3
SECTION A: 8 Pain in tooth or mouth
0
1
2
3
SECTION A: 9 Periodontal disease
0
1
2
3
SECTION A: 10 Sensitivity to hot or cold foods
0
1
2
3
SECTION A: 11 Sores in your mouth
0
1
2
3
SECTION A: 12 Swelling of the jaw
0
1
2
3
SECTION A: 13 White patches on your tongue or cheeks
0
1
2
3
SECTION A: YOUR SCORE
SECTION B: 1 Problems with swallowing or painful swallowing (dysphagia)
0
1
2
3
SECTION B: 2 Food gets stuck/impacted in esophagus after swallowing
0
1
2
3
SECTION B: 3 Need to regurgitate or vomit food and/or nausea
0
1
2
3
SECTION B: 4 GERD medications, such as proton pump inhibitors, don’t help the problem
0
1
2
3
SECTION B: 5 Chest or abdominal pain with eating
0
1
2
3
SECTION B: 6 Heartburn or GERD
0
1
2
3
SECTION B: YOUR SCORE
SECTION C: 1 Burping or bloated right after eating
0
1
2
3
SECTION C: 2 Feels like food sits in stomach
0
1
2
3
SECTION C: 3 History of allergies or autoimmune disease
0
1
2
3
SECTION C: 4 Easily get food poisoning
0
1
2
3
SECTION C: 5 Stomach upsets easily
0
1
2
3
SECTION C: 6 History of constipation
0
1
2
3
SECTION C: 7 Known food allergies
0
1
2
3
SECTION C: 8 Iron deficiency anemia
0
1
2
3
SECTION C: 9 Nausea after taking supplements
0
1
2
3
SECTION C: 10 Undigested food in stool
0
1
2
3
SECTION C: 11 History of small intestinal bacterial overgrowth
0
1
2
3
SECTION C: 12 Age 75-79 = 1 point, age 80-84 = 2 points, age ≥85 = 3 points
0
1
2
3
SECTION C: 13 Takes antacids or Proton Pump Inhibitors (PPIs)
0
1
2
3
SECTION C: 14 Pruritis ani (itchy anus)
0
1
2
3
SECTION C: YOUR SCORE
SECTION D: 1 Sour taste in mouth
0
1
2
3
SECTION D: 2 Regurgitate undigested food into mouth
0
1
2
3
SECTION D: 3 Frequent coughing
0
1
2
3
SECTION D: 4 Burning sensation from citrus in throat
0
1
2
3
SECTION D: 5 Heartburn
0
1
2
3
SECTION D: 6 Burping
0
1
2
3
SECTION D: 7 Difficulty swallowing solids or liquids
0
1
2
3
SECTION D: YOUR SCORE
SECTION E: 1 Abdominal cramps
0
1
2
3
SECTION E: 2 Indigestion one to three hours after eating
0
1
2
3
SECTION E: 3 Fatigue after eating
0
1
2
3
SECTION E: 4 Lower bowel gas
0
1
2
3
SECTION E: 5 Alternating constipation & diarrhea
0
1
2
3
SECTION E: 6 Diarrhea
0
1
2
3
SECTION E: 7 Roughage & fiber causes constipation
0
1
2
3
SECTION E: 8 Mucus in stools
0
1
2
3
SECTION E: 9 Stool poorly formed
0
1
2
3
SECTION E: 10 Shiny stool
0
1
2
3
SECTION E: 11 Three or more large bowel movements daily
0
1
2
3
SECTION E: 12 Dry, flaky skin &/or dry brittle hair
0
1
2
3
SECTION E: 13 Pain in left side under rib cage or chronic stomach pain
0
1
2
3
SECTION E: 14 Adult acne
0
1
2
3
SECTION E: 15 Food allergies
0
1
2
3
SECTION E: 16 Difficulty gaining weight
0
1
2
3
SECTION E: 17 Foul-smelling stool
0
1
2
3
SECTION E: 18 Gallstones/history of gallbladder disease
0
1
2
3
SECTION E: 19 Undigested food in stool
0
1
2
3
SECTION E: 20 Nausea
0
1
2
3
SECTION E: 21 Acid reflux/heartburn
0
1
2
3
SECTION E: 22 Connective tissue disease: lupus, RA, Sjogren’s
0
1
2
3
SECTION E: 23 Alcoholism, diabetes, osteoporosis
0
1
2
3
SECTION E: YOUR SCORE
SECTION F: 1 Stomach pains
0
1
2
3
SECTION F: 2 Stomach pains before or after meals
0
1
2
3
SECTION F: 3 Dependency on antacids or PPIs for heartburn/GERD
0
1
2
3
SECTION F: 4 Chronic abdominal pain
0
1
2
3
SECTION F: 5 Butterfly sensations in stomach
0
1
2
3
SECTION F: 6 Burping or bloating
0
1
2
3
SECTION F: 7 Stomach pain when emotionally upset
0
1
2
3
SECTION F: 8 Sudden, acute indigestion
0
1
2
3
SECTION F: 9 Relief of symptoms by carbonated drinks
0
1
2
3
SECTION F: 10 Relief of stomach pain by drinking cream/milk
0
1
2
3
SECTION F: 11 History or family history of ulcer or gastritis
0
1
2
3
SECTION F: 12 Current ulcer
0
1
2
3
SECTION F: 13 Black stool when not taking iron supplements
0
1
2
3
SECTION F: 14 Use or previous use of pain medications: aspirin, ibuprofen, etc.
0
1
2
3
SECTION F: YOUR SCORE
SECTION G: 1 Lactose intolerance, fructose intolerance or sucrose intolerance
0
1
2
3
SECTION G: 2 Undigested food in your stools
0
1
2
3
SECTION G: 3 Abdominal discomfort, bloating, gas
0
1
2
3
SECTION G: 4 Bleeding tendency (vitamin K deficiency)
0
1
2
3
SECTION G: 5 Can’t gain weight
0
1
2
3
SECTION G: 6 Fatigue for no obvious reason
0
1
2
3
SECTION G: 7 Food sensitivities
0
1
2
3
SECTION G: 8 Transient low blood sugar
0
1
2
3
SECTION G: 9 Malabsorption issues
0
1
2
3
SECTION G: 10 Pale or tan colored stools, may be frothy and smell bad
0
1
2
3
SECTION G: 11 Stools that float
0
1
2
3
SECTION G: YOUR SCORE
SECTION H: 1 Trouble digesting food with fats and oils
0
1
2
3
SECTION H: 2 Jaundice or yellow colored whites of eyes
0
1
2
3
SECTION H: 3 Nausea and vomiting
0
1
2
3
SECTION H: 4 Feeling queasy after a fatty meal
0
1
2
3
SECTION H: 5 Feeling of fullness and deferred pain to head, belly, shoulder blades
0
1
2
3
SECTION H: 6 Have had gallbladder removed or have gallstones
0
1
2
3
SECTION H: 7 Light or tan colored, frothy stools, smell bad
0
1
2
3
SECTION H: 8 Diarrhea
0
1
2
3
SECTION H: 9 Gas and bloating
0
1
2
3
SECTION H: 10 Low serum albumin levels
0
1
2
3
SECTION H: 11 Bleeding tendency (vitamin K deficiency)
0
1
2
3
SECTION H: 12 Less than one bowel movement daily
0
1
2
3
SECTION H: 13 Itchy skin
0
1
2
3
SECTION H: 14 Lack of appetite
0
1
2
3
SECTION H: 15 Dark colored urine
0
1
2
3
SECTION H: 16 Having a bitter taste or sour taste in your mouth after eating
0
1
2
3
SECTION H: 17 Water retention in legs and ankles
0
1
2
3
SECTION H: 18 Big toe painful
0
1
2
3
SECTION H: 19 Pain radiates along outside of leg
0
1
2
3
SECTION H: 20 Dry skin/hair
0
1
2
3
SECTION H: 21 Red blood in stool
0
1
2
3
SECTION H: 22 Have had jaundice or hepatitis
0
1
2
3
SECTION H: 23 High blood cholesterol and/or triglycerides
0
1
2
3
SECTION H: YOUR SCORE
SECTION I: 1 Nausea
0
1
2
3
SECTION I: 2 Diarrhoea
0
1
2
3
SECTION I: 3 Abdominal pain or discomfort
0
1
2
3
SECTION I: 4 Neurological issues including brain fog, depression difficulty focusing or remembering
0
1
2
3
SECTION I: 5 Rashes or hives
0
1
2
3
SECTION I: 6 Unexplained fatigue, joint pain or muscle pain
0
1
2
3
SECTION I: 7 Diagnosed with autoimmune disorder
0
1
2
3
SECTION I: 8 Digestive issues
0
1
2
3
SECTION I: YOUR SCORE
SECTION J: 1 Itching, rash, hives or flushing
0
1
2
3
SECTION J: 2 Itching or tingling in the mouth or on tongue
0
1
2
3
SECTION J: 3 Swollen lips, face, tongue, throat, etc.
0
1
2
3
SECTION J: 4 Symptoms come on rapidly after eating
0
1
2
3
SECTION J: 5 Chronic sinusitis
0
1
2
3
SECTION J: 6 Nausea and/or abdominal cramping
0
1
2
3
SECTION J: 7 Diagnosed with allergies: i.e. hay fever, asthma, eczema
0
1
2
3
SECTION J: 8 Diarrhoea
0
1
2
3
SECTION J: 9 Dizziness, fainting, lightheaded
0
1
2
3
SECTION J: YOUR SCORE
SECTION K: 1 Constipation and/or diarrhea
0
1
2
3
SECTION K: 2 Abdominal pain or bloating
0
1
2
3
SECTION K: 3 Mucus or blood in stool
0
1
2
3
SECTION K: 4 Joint pain or swelling, or arthritis
0
1
2
3
SECTION K: 5 Chronic or frequent fatigue or tiredness
0
1
2
3
SECTION K: 6 Food allergy or food sensitivities or intolerances
0
1
2
3
SECTION K: 7 Sinus or nasal congestion
0
1
2
3
SECTION K: 8 Chronic or frequent inflammations
0
1
2
3
SECTION K: 9 Eczema, skin rashes, or hives (urticaria)
0
1
2
3
SECTION K: 10 Asthma, hay fever, or airborne allergies
0
1
2
3
SECTION K: 11 Confusion, poor memory, or mood swings
0
1
2
3
SECTION K: 12 Use of non-steroidal anti-inflammatory drugs (aspirin, ibuprofen)
0
1
2
3
SECTION K: 13 History of antibiotic use
0
1
2
3
SECTION K: 14 Alcohol consumption, or alcohol makes you feel sick
0
1
2
3
SECTION K: 15 Ulcerative colitis, Crohn’s disease, or celiac disease
0
1
2
3
SECTION K: 16 Headaches or migraine headaches
0
1
2
3
SECTION K: 17 Chronic nasal congestion
0
1
2
3
SECTION K: YOUR SCORE
SECTION L: 1 Stomach pains
0
1
2
3
SECTION L: 2 Stomach pains before or after meals
0
1
2
3
SECTION L: 3 Abdominal bloating and distension, especially with sugar fiber or carbohydrates
0
1
2
3
SECTION L: 4 Abdominal pain, cramping, mucus or blood in stools
0
1
2
3
SECTION L: 5 Irritable bowel syndrome
0
1
2
3
SECTION L: 6 Fibromyalgia
0
1
2
3
SECTION L: 7 Restless leg syndrome
0
1
2
3
SECTION L: 8 Interstitial cystitis
0
1
2
3
SECTION L: 9 Chronic constipation
0
1
2
3
SECTION L: 10 Intolerance to probiotic supplements
0
1
2
3
SECTION L: 11 Scored 9 or more on section A
0
1
2
3
SECTION L: 12 Currently taking antacids or proton pump inhibitors
0
1
2
3
SECTION L: 13 Fatigue/Low energy
0
1
2
3
SECTION L: 14 Depression or anxiety
0
1
2
3
SECTION L: 15 Bad breath
0
1
2
3
SECTION L: YOUR SCORE
SECTION M: 1 Recurring vaginal, nail, skin or other fungal infections
0
1
2
3
SECTION M: 2 Diarrhea, constipation or both
0
1
2
3
SECTION M: 3 Unexplained fatigue and/or brain fog
0
1
2
3
SECTION M: 4 Depression and/or anxiety
0
1
2
3
SECTION M: 5 Chronic sinusitis
0
1
2
3
SECTION M: 6 Itching in vagina, anus, ears, or other mucus membranes
0
1
2
3
SECTION M: 7 Gas and/or bloating
0
1
2
3
SECTION M: 8 Diagnosis of autoimmune disease
0
1
2
3
SECTION M: 9 Skin issues: eczema, psoriasis, hives, rashes
0
1
2
3
SECTION M: 10 Low blood sugar issues, mood swings
0
1
2
3
SECTION M: YOUR SCORE
SECTION N: 1 Bloating and/or gas
0
1
2
3
SECTION N: 2 Constipation and/or diarrhoea
0
1
2
3
SECTION N: 3 Nausea
0
1
2
3
SECTION N: 4 Weight trouble
0
1
2
3
SECTION N: 5 Iron-deficiency anemia
0
1
2
3
SECTION N: 6 Fatigue
0
1
2
3
SECTION N: 7 Sleep problems
0
1
2
3
SECTION N: 8 Depression, anxiety and/or mood swings
0
1
2
3
SECTION N: 9 Menstrual problems
0
1
2
3
SECTION N: 10 Infertility
0
1
2
3
SECTION N: 11 Thyroid problems
0
1
2
3
SECTION N: 12 Osteoporosis or osteopenia
0
1
2
3
SECTION N: 13 Headaches and/or migraines
0
1
2
3
SECTION N: 14 Memory problems
0
1
2
3
SECTION N: 15 Joint pains or aches
0
1
2
3
SECTION N: 16 Fibromyalgia
0
1
2
3
SECTION N: 17 Brain fog
0
1
2
3
SECTION N: 18 Get infections easily
0
1
2
3
SECTION N: 19 Arthritis, any type, you or family
0
1
2
3
SECTION N: 20 Cancer history, you or family
0
1
2
3
SECTION N: 21 Autoimmune disease, you or family
0
1
2
3
SECTION N: 22 Celiac disease, you or family
0
1
2
3
SECTION N: YOUR SCORE
SECTION O: 1 Seasonal or recurring diarrhea
0
1
2
3
SECTION O: 2 Frequent and recurrent infections (colds)
0
1
2
3
SECTION O: 3 Bladder and kidney infections
0
1
2
3
SECTION O: 4 Vaginal yeast infection
0
1
2
3
SECTION O: 5 Abdominal cramps
0
1
2
3
SECTION O: 6 Toe and fingernail fungus 7 Alternating diarrhoea/constipation
0
1
2
3
SECTION O: 7 Alternating diarrhea/constipation
0
1
2
3
SECTION O: 8 Constipation
0
1
2
3
SECTION O: 9 History of antibiotic use
0
1
2
3
SECTION O: 10 Meat eater
0
1
2
3
SECTION O: 11 Rapidly failing vision
0
1
2
3
SECTION O: 12 Recurrent stomach pain
0
1
2
3
SECTION O: 13 Blood or pus in stool
0
1
2
3
SECTION O: 14 Family history of IBD
0
1
2
3
SECTION O: YOUR SCORE
Adapted with permission from: Dr. Liz Lipski "Digestive Health Appraisal Questionnaire".
Submit
Δ
