Digestive and Lifestyle Symptoms Assessment

HARRIS INTEGRATED HEALTH AND NUTRITION

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BrainSustain Vanilla Delight 10 Servings
BrainSustain Vanilla Delight 10 Servings

Digestive and Lifestyle Symptoms Assessment

PLEASE FILL OUT FORM AS BEST YOU CAN AND SUBMIT IT BY CLICKING THE BUTTON BELOW

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Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Occupation *

Phone Number *

Height *

Weight *

Marital Status *

Number of Children *

Date *

Email *

Date of Birth *

Gender *

Do You Follow a Specific Diet/Nutritional Program *

How Often do You Weigh Yourself *

Medications Currently Used *

Antacids Antibiotics Antifungals Anti-Inflammatories Aspirin Cortisone Laxatives Oral Contraceptives Prednisone Stool Softeners Tylenol Ulcer Medications

Check All That Apply

Please Indicate the Materials You Use for Cooking and/or Storage *

Plastic Glass Aluminum Styrofoam Stainless Steel Cast - Iron Teflon/Non - Stick Ceramic

Check All That Apply

Hypoacidity of the Stomach *

Burping or Feeling Bloated Right After a Meal Feels Like Food Sits in Your Stomach History of Allergies or Autoimmune Disease Stomach Upsets Easily History of Constipation Known Food Allergies Iron-Deficiency Anemia Nausea After Taking Supplements Undigested Food in Stool History of Small Intestinal Bacterial Overgrowth (SIBO) Takes Antacids or Proton Pump Inhibitors (PPIs Pruritis Ani (Itchy Anus)

Check All That Apply

Hypofunction of Small Intestines and/or Pancreas *

Abdominal Cramps Indigestion 1-3 Hours After Eating Fatigue After Eating Lower Bowel Gas Alternating Constipation and Diarrhea Diarrhea Roughage and Fiber Cause Consipation Mucus in Stools Stool Poorly Formed Shiny Stool Three or More Bowel Movements Daily Dry, Flaky Skin and/or Dry, Brittle Hair Pain in Left Side Under Rib Cage or Chronic Stomach Pain Acne Food Allergies Difficulty Gaining Weight Foul-Smelling Stool Gallstones/History of Gallbladder Disease Undigested Food in Stool Nausea Acid Reflux/Heartburn Connective Tissue Disease; Lupus, Rheumatoid Arthritis, Sjorren's Alcoholism, Diabetes, Osteoporosis

Check All That Apply

Enzyme Insufficiencies *

Lactose Intolerance, Fructose Intolerance or Sucrose Intolerance Undigested Food in Your Stools Abdominal Discomfort, Bloating, Gas Bleeding tendency (Vitamin K Deficiency) Can't Gain Weight Fatigue for No Obvious Reason Food Sensitivities Transient Low Blood Sugar Malabsorption Issues Pale or Tan-Colored Stools, May Be Frothy and Smell Bad Stools That Float

Food Sensitivities *

Nausea Diarrhea Abdominal Pain or Discomfort Neurological Issues, Including Brain Fog, Depression, Difficulty Focusing or Remembering Rashes or Hives Unexplained Fatigue, Joint Pain or Muscle Pain Diagnosed with Autoimmune Disorder Digestive Issues

Intestinal Permeability/Leaky Gut Syndrome Dysbiosis *

Constipation and/or Diarrhea Abdominal Pain or Bloating Mucus or Blood in Stool Joint Pain or Swelling, or Arthritis Chronic or Frequent Fatigue or Tiredness Food Allergy or Food Sensitivities or Intolerances Sinus or Nasal Congestion Chronic or Frequent Inflammations Eczema, Skin Rashes, or Hives (Urticaria) Asthma, Hay Fever or Airborne Allergies Confusion, Poor Memory or Mood Swings Use of Nonsteroidal Anti-Inflammatory Drugs (NSAIDs), Such as Aspirin, Ibuprofen, History of Antibiotic Use Alcohol Consumption, Alcohol Makes You Feel Sick An Autoimmune Disorder Including, but Not Limited to; Ulcerative Colitis, Crohn's Disease, Celiac Disease, Hashimoto's Thyroiditis, Grave's Disease, Multiple Sclerosis, Lupus, Rheumatoid Arthritis, etc. Headaches or Migraine Headaches Chronic Nasal Congestion

Dysbiosis; Fungal Overgrowth *

Recurring Vaginal, Nail, Skin or Other Fungal Infections Diarrhea, Constipation or Both Unexplained fatigue and/or Brain Fog Depression and/or Anxiety Chronic Sinusitis Itching in vagina, Anus, Ears or Other Mucus Membraines Gas and/or Bloating Diagnosis of Autoimmune Disease Skin Issues; Eczema, Psoriasis, Hives, Rashes Low Blood Sugar Issues, Mood Swings

Colon/Large Intestine *

Seasonal or Recurring Diarrhea Frequent and Recurrent Infections (Colds) Bladder and Kidney Infections Vaginal Yeast Infections Abdominal Cramps Toe and Fingernail Fungus Alternating Diarrhea and Constipation Constipation History of Antibiotic Use Meat eater Rapidly Failing Vision Recurrent Stomach Pain Blood or Pus in Stool Family History of Inflammatory Bowel Disease

Would You Describe Your Stools; *

How Often do You Cook Meals From Scratch? *

How Often do You Eat Meals at Home *

How Often do You Eat Meals Out? *

Have You Ever Had a Nutrition Consultation *

Have You Made Any Changes in Your Eating Habits Because of Health Issues *

Food, Nutrition and Lifestyle *

Alcohol Candy Chewing Tobacco Cigarettes Coffee Fast Foods Fried Foods Luncheon Meats Fresh Fruits and Vegetables Nuts and Seeds Beans, Lentils and Peas Margarine Soft Drinks Sweets and/or Pasteries

Check All That Apply

Miscellaneous *

Diet Often Do Not Exercise Regularly Are Under Excessive Stress Are Exposed to Chemicals at Work Are Exposed to Cigarette Smoke Do You Regularly Eat Dinner/Supper Do You Regularly Eat Snacks

Check All That Apply

Do You Often Experience the Following Symptoms *

Heartburn Gas Bloating Stomach Pain Nausea/Vomiting Diarrhea Constipation

Check All That Apply

Gastric Reflux *

Sour Taste in Mouth Regurgitate Undigested Food into Mouth Frequent Chronic Coughing Burning Sensation From Citrus on way to Stomach Heartburn Burping Difficulty Swallowing Solids or Liquids

Check All That Apply

Ulcers or Too Much Stomach Acid *

Stomach Pains Stomach Pains Before or After Meals Dependency on Antacids for Heartburn/Acid Reflux Chronic Abdominal Pain Butterfly Sensations in Stomach Burping or Bloating Stomach Pain When Emotionally Upset Sudden, Acute Indigestion Relief of Symptoms by Carbonated Drinks Relief of Stomach Pain by Drinking Cream or Milk History or Family History of Ulcer or Gastritis Current Ulcer Black Stool When Not Taking Iron Supplements Use or Previous Use of Pain medications; Aspirin,Ibuprofen, etc.

Liver/Gallbladder *

Trouble Digesting Food With Fats and Oils Jaundice or Yellow-Colored Whites of Eyes Nausea and Vomitting Feeling Queasy After a Fatty Meal Feeling of Fullness with Deferred Pain to Head, Belly, Shoulder Blades Have Had Your Gallbladder Removed or Have Gallstones Light-or Tan-Colored, Frothy Stools, Smell Bad Diarrhea Gas or Bloating Low Serum Albumin levels Bleeding Tendency (Vitamin K Deficiency) Less Than One Bowel Movement Daily Itchy Skin Lack of Appetite Dark-Colored Urine Having a Bitter or Sour Taste in Your Mouth After Eating Water Retention in Legs and Ankles Big Toe Painful Pain Radiates Along Outside of Leg DrySkin/Hair Red Blood in Stool Have Had Jaundice or Hepatitis High Blood Cholesterol and/or Triglycerides

Food Allergies *

Itching, Rash, Hives or Flushing Itching or Tingling in the Mouth or on Tongue Swollen Lips, Face, Tongue, Throat etc. Symptoms Come On Rapidly After Eating Chronic Sinusitis Nausea and/or Abdominal Cramping Diagnosed With Allergies (Hay Fever, Asthma,Eczema) Diarrhea Dizziness, Fainting, Lightheaded

Small Bowel Bacterial Overgrowth *

Excessive Gas/Flatulence Abdominal Bloating and Distension, Especially with Sugar, Fiber or Carbohydrates Diarrhea Abdominal Pain, Cramping, Mucus or Blood in Stools Irritable Bowel Syndrome (IBS) Fibromyalgia Restless Leg Syndrome Intestinal Cystitis Chronic Constipation Intolerance to Probiotic Supplements Currently Taking Antacids or Proton Pump inhibitors (PPIs) Fatigue/ Low Energy Depression or Anxiety Bad Breath

Celiac Disease, Gluten Sensitivity, Wheat Reactions (Digestive) *

Bloating and/or Gas Constipation and/or Diarrhea Nausea Weight Trouble Iron-Deficiency Anemia

Celiac Disease, Gluten Sensitivity, Wheat Reactions (Hormonal) *

Fatigue Sleep Problems Depression, Anxiety, and/or Mood Swings Menstrual Problems Infertility Thyroid Problems Osteoporosis or Osteopenia

Neurological *

Headaches and/or Migraines Memory problems Joint Pains or Aches Fibromyalgia Brain Fog

Immune System *

Get Infections Easily History or Family History of Arthritis, Any Type History or Family History of Cancer History or Family History of Autoimmune Disease History or Family History of Celiac Disease

Please List Supplements You Take Regularly *

Submit

Digestive and Lifestyle Symptoms Assessment

PLEASE FILL OUT FORM AS BEST YOU CAN AND SUBMIT IT BY CLICKING THE BUTTON BELOW ​

PLEASE FILL OUT FORM AS BEST YOU CAN AND SUBMIT IT BY CLICKING THE BUTTON BELOW