Digestive Health Appraisal Questionairre

HARRIS INTEGRATED HEALTH AND NUTRITION

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Digestive Health Appraisal Questionairre

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

* Indicates required field

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 *

Section A; Oral and Dental Health

A sore in your mouth that doesn't heal *

0 1 2 3

Canker sores or cold sores *

0 1 2 3

Dry mouth/Poor salivation *

0 1 2 3

Loose teeth or receding gums *

0 1 2 3

Bleeding or swelling after you floss or brush your teerth *

0 1 2 3

Chronic bad breath or sour taste in mouth *

0 1 2 3

Fissures in your tongue or geographic tongue (red Patches) *

0 1 2 3

Pain in tooth or mouth *

0 1 2 3

Periodontal Disease *

0 1 2 3

Sensitivity to hot or cold foods *

0 1 2 3

Sores in your mouth *

0 1 2 3

White patches on your tongue or cheeks *

0 1 2 3

Swelling of the jaw *

0 1 2 3

Your Score *

Section B; Eosinophilic Esophagitis and Esophagitis

Problems with swallowing or painful swallowing (dysphagia) *

0 1 2 3

Food gets stuck/impacted in esophagus after swallowing *

0 1 2 3

Need to regurgitate or vomit food and/or nausea *

0 1 2 3

GERD medications, such as proton pump inhibitors, don't help the problem *

0 1 2 3

Chest or abdominal pain with eating *

0 1 2 3

Heartburn or GERD *

0 1 2 3

Your Score *

Section C; Hypoacidity of the Stomach

Burping or bloating right after eating *

0 1 2 3

Feels like food sits in your stomach *

0 1 2 3

History of allergies or autoimmune disease *

0 1 2 3

Easily get food poisoning *

0 1 2 3

Stomach upsets easily *

0 1 2 3

History of constipation *

0 1 2 3

Known food allergies *

0 1 2 3

iron deficiency anemia *

0 1 2 3

Nausea after taking supplements *

0 1 2 3

Undigested food in stool *

0 1 2 3

History of small intestinal bacterial overgrowth *

0 1 2 3

Age 75-79 =1 point, age 80-84=2 points, age >85=3 points *

0 1 2 3

Takes antacids or Proton Pump Inhibitors (PPIs) *

0 1 2 2

Pruritis ani (itchy anus) *

0 1 2 3

Your Score *

SectionD; Gastic Reflux

Sour taste in mouth *

0 1 2 3

Regurgitate undigested food *

0 1 2 3

Frequent Coughing *

0 1 2 3

Burning sensation from citrus in throat *

0 1 2 3

Heartburn *

0 1 2 3

Burping *

0 1 2 3

Difficulty swallowing solids or liquids *

0 1 2 3

Your Score *

Section E; Hypofunction of Small Intestine and/or Pancreas

Abdominal cramps *

0 1 2 3

Indigestion one to three hours after eating *

0 1 2 3

Fatigue after eating *

0 1 2 3

Lower bowel gas *

0 1 2 3

Alternating constipation and diarrhea *

0 1 2 3

Diarrhea *

0 1 2 3

Roughage and fiber causes constipation *

0 1 2 3

Mucus in stools *

0 1 2 3

Stool poorly formed *

0 1 2 3

Shiny stool *

0 1 2 3

Three or more large bowel movements daily *

0 1 2 3

Dry, flaky skin and/or dry brittle hair *

0 1 2 3

Pain in left side under rib cage or chronic stomach pain *

0 1 2 3

Adult acne *

0 1 2 3

Food allergies *

0 1 2 3

Difficulty gaining weight *

0 1 2 3

Foul-smelling stool *

0 1 2 3

Gallstones/history of gallbladder disease *

0 1 2 3

Undigested food in stool *

0 1 2 3

Nauseea *

0 1 2 3

Acid reflux/heartburn *

0 1 2 3

Alcoholism, diabetes,osteoporosis *

0 1 2 3

Connective tissue disorder: lupus, RA, Sjogren's *

0 1 2 3

Your Score *

Section F; Ulcers

Stomach pain *

0 1 2 3

Stomach pains before or after meals *

0 1 2 3

Dependency on antacids or PPIs for heartburn/GERD *

0 1 2 3

Chronic abdominal pain *

0 1 2 3

Butterfly sensations in stomach *

0 1 2 3

Burping or bloating *

0 1 2 3

Stomach pain when emotionally upset *

0 1 2 3

Sudden, acute indigestion *

0 1 2 3

Relief of symptoms by carbonated drinks *

0 1 2 3

Relief of stomach pain by drinking cream/milk *

0 1 2 3

History or family history of ulcer or gastritis *

0 1 2 3

Current ulcer *

0 1 2 3

Black stool when not taking iron supplements *

0 1 2 3

Use or previous use of pain medications: aspirin, ibuprofen, etc. *

0 1 2 3

Your Score *

Section G; Enzyme Insufficiencies

Lactose intolerance, fructose intolerance or sucrose intolerance *

0 1 2 3

Undigested food in your stools *

0 1 2 3

Abdominal discomfort, bloating, gas *

0 1 2 3

Bleeding tendency (vitamin K deficiency) *

0 1 2 3

Can't gain weight *

0 1 2 3

Fatigue for no obvious reason *

0 1 2 3

Food sensitivities *

0 1 2 3

Transient low blood sugar *

0 1 2 3

Malabsorption issues *

0 1 2 3

Pale or tan colored stools, may be frothy and smell bad *

0 1 2 3

Stools that float *

0 1 2 3

Your Score *

Section H; Liver/Gallbladder

Trouble digesting food with fats and oils *

0 1 2 3

Jaundice or yellow colored whites of eyes *

0 1 2 3

Nausea and vomitng *

0 1 2 3

Feeling queasy after a fatty meal *

0 1 2 3

Feeling of fullness and deferred pain to head, belly, shoulder blades *

0 1 2 3

Have had gallbladder removed or have gallstones *

0 1 2 3

Light or tan colored, frothy stools, smell bad *

0 1 2 3

Diarrhea *

0 1 2 3

Gas or bloating *

0 1 2 3

Low serum albumin levels *

0 1 2 3

Bleeding tendency (vitamin K deficiency) *

0 1 2 3

Less than one bowel movemnet daily *

0 1 2 3

Itchy skin *

0 1 2 3

Lack of appetite *

0 1 2 3

Dark colored urine *

0 1 2 3

Having a bitter taste or sour taste in your mouth after eating *

0 1 2 3

Water retention in legs and ankles *

0 1 2 3

Big toe painful *

0 1 2 3

Pain radiates along outside of leg *

0 1 2 3

Dry skin/hair *

0 1 2 3

Red blood in stool *

0 1 2 3

Have had jaundice or hepatitis *

0 1 2 3

High blood cholesterol and/or triglycerides *

0 1 2 3

Your Score *

Section I; Food Sensitivities

Nausea *

0 1 2 3

Diarrhea *

0 1 2 3

Abdominal pain or discomfort *

0 1 2 3

Neurological issues including brain fog, depression difficulty focusing or remembering *

0 1 2 3

Rashes or hives *

0 1 2 3

Unexplained fatigue, joint pain or muscle pain *

0 1 2 3

Diagnosed with autoimmune disorder *

0 1 2 3

Digestive issues *

0 1 2 3

Your Score *

Section J; Food Allergies

Itching, rash, hives or flushing *

0 1 2 3

Itching or tingling in the mouth or in the tongue *

0 1 2 3

Swollen lips, face, tongue, throat, etc. *

0 1 2 3

Symptoms come on rapidlyafter eating *

0 1 2 3

Chronic sinusitis *

0 1 2 3

Nausea and/or abdominal cramping *

0 1 2 3

Diagnosed with allergies: i.e. hay fever, asthma, eczema *

0 1 2 3

Diarrhea *

0 1 2 3

Dizziness *

0 1 2 3

Your Score *

Section; K Intestinal Permeability/Leaky Gut or Dysbiosis

Constipation and/or diarrhea *

0 1 2 2

Abdominal pain or bloating *

0 1 2 3

Mucus or blood in stool *

0 1 2 3

Joint pain or swelling or arthritis *

0 1 2 3

Chronic or frequent fatigue or tiredness *

0 1 2 3

Food allergies or food sensitivities or intolerances *

0 1 2 3

Sinus or nasal congestion *

0 1 2 3

Chronic or frequent inflammation *

0 1 2 2

Eczema, skin rashes or hives (urticaria) *

0 1 2 3

Chronic nasal congestion *

0 1 2 3

Asthma, hay fever, or airborne allergies *

0 1 2 3

Confusion, poor memory, or mood swings *

0 1 2 3

Use of non-steroidal anti-inflammatory drugs (aspirin, ibuprofin) *

0 1 2 3

History of antibiotic use *

0 1 2 3

Alcohol consumption, or alcohol makes you feel sick *

0 1 2 3

Ulcerative colitis, Crohn's disease, or celiac disease *

0 1 2 3

Headaches or migraine headaches *

0 1 2 3

Your Scote *

Section L; Small Intestinal Bacterial Overgrowth

Stomach pains *

0 1 2 3

Stomach pains before or after meals *

0 1 2 3

Abdominal bloating and distension, especially with sugar fiber or carbohydrates *

0 1 2 3

Abdominal pain, cramping, mucous or blood in stools *

0 1 2 3

Irritable bowel syndrome *

0 1 2 3

Fibromyalgia *

0 1 2 3

Restless leg syndrome *

0 1 2 3

Intestinal cystitis *

0 1 2 3

Chronic constipation *

0 1 2 3

Intolerance to probiotic supplements *

0 1 2 3

Scored 9 or more on section A *

0 1 2 3

Currently taking antacids or proton pump inhibitors *

0 1 2 3

Fatigue/Low energy *

0 1 2 3

Depression or anxiety *

0 1 2 3

Bad breath *

0 1 2 3

Your Score *

Section M; Dysbiosis: Fungal Overgrowth

Recurring vaginal, nail, skin or other fungal infections *

0 1 2 3

Diarrhea, constipation or both *

0 1 2 3

Unexplained fatigue and/or brain fog *

0 1 2 3

Depression and/or anxiety *

0 1 2 3

Chronic sinusitis *

0 1 2 3

Itching in vagina, anus, ears, or other mucus membranes *

0 1 2 3

Gas and/or bloating *

0 1 2 3

Diagnosis of autoimmune disease *

0 1 2 3

Skin issues: eczema, psoriasis, hives, rashes *

0 1 2 3

Low blood sugar issues, mood swings *

0 1 2 3

Your Score *

Section N; Celiac Disease, Gluten Sensitivity, Wheat Reactions

Digestive

Bloating and/or gas *

0 1 2 3

Constipation and/or diarrhea *

0 1 2 3

Nausea *

0 1 2 3

Weight Trouble *

0 1 2 3

iron-deficiency anemia *

0 1 2 3

Hormonal

Fatigue *

0 1 2 3

Sleep problems *

0 1 2 3

Depression, anxiety and/or mood swings *

0 1 2 3

Menstrual problems *

0 1 2 3

Infertility *

0 1 2 3

Thyroid problems *

0 1 2 3

Osteoporosis or osteopenia *

0 1 2 3

Neurological

Headaches and/or migraines *

0 1 2 3

Memory problems *

0 1 2 3

Joint pains or aches *

0 1 2 3

Fibromyalgia *

0 1 2 3

Brain fog *

0 1 2 3

Immune System

Get infections easily *

0 1 2 3

Arthritis, any type, you or family *

0 1 2 3

Cancer history, you or family *

0 1 2 3

Autoimmune disease, you or family *

0 1 2 3

Celiac disease, you or family *

0 1 2 3

Your Score *

Section O; Colon/Large Intestine

Seasonal or recurring diarrhea *

0 1 2 3

Frequent and recurrent infections (colds) *

0 1 2 3

Bladder and kidney infections *

0 1 2 3

Vaginal yeast infections *

0 1 2 3

Abdominal cramps *

0 1 2 3

Toe and fingernail fungus *

0 1 2 3

Alternating diarrhea/constipation *

0 1 2 3

Constipation *

0 1 2 3

History of antibiotic use *

0 1 2 3

Meat eater *

0 1 2 3

Rapidly failing vision *

0 1 2 3

Recurrent stomach pain *

0 1 2 3

Blood or pus in stool *

0 1 2 3

Family history of IBD *

0 1 2 3

Your Score *

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Welcome
Programs
- From a Distance >
- Eye to Eye >
Diet Lifestyle Environment
Resources
Cancer
- Cancer
Products
Services
- Eye to Eye >
- From a Distance >
Books
- Book; Our Modern Mortal Trilogy
NitroGreens
New Client Register/Sign In
BrainSustain Vanilla Delight 10 Servings
BrainSustain Vanilla Delight 10 Servings