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| Understanding key contributors to gastrointestinal (GI) health will help identify the best course of action for recovery of GI function. After reviewing this questionnaire with your health care provider, please refer to the Pillars of GI Health Patient Handbook for dietary, lifestyle and nutrient therapy recommendations. |
Please list your top 3
major health concerns in
order of importance: |
|
Do you consume at least
five servings of fruits
and vegetables per day? |
|
Do you drink at least
eight 8 oz glasses of
water every day? |
|
Do you regularly consume
soft drinks or fruit
juices? |
|
Have you ever been
diagnosed with a chronic
GI condition? |
|
Do you experience
frequent heartburn,
burping, gas or bloating
during or immediately
after meals? |
|
Have you ever been
diagnosed with anemia or
any other nutrient
deficiency? |
|
Have you ever been placed
on a heartburn medication
(proton pump inhibitor
[PPI] or H2 blocker)? |
|
Do you frequently
experience indigestion? |
|
Do you regularly have
less than one or more
than three bowel
movements per day? |
|
Do you take a laxative
more than twice a month? |
|
Are you sensitive to
smells or fragrances? |
|
Do you have regular
exposure to exhaust
fumes, tobacco smoke,
pesticides, commercial
chemicals, paint,
cleaning chemicals or
volatile fumes? |
|
Have you used antibiotics
within the past two
years? |
|
Do you experience
abdominal bloating, pain,
gas, constipation or
diarrhea? |
|
Have you ever been
diagnosed with chronic
fatigue syndrome,
fibromyalgia or irritable
bowel syndrome? |
|
Do you experience poor
memory, difficulty
concentrating or brain
fog? |
|
Have you ever been
diagnosed with
depression, anxiety, ADD
or ADHD? |
|
Do you suffer from
multiple food
sensitivities? |
|
Do you experience skin
issues such as acne,
rosacea or eczema? |
|
Do you have seasonal
allergies, asthma or an
autoimmune disease? |
|
Disclaimer: This tool does not provide medical advice. It is intended for informational purposes only. It is not a substitute for professional medical advice, diagnosis or treatment. Never ignore professional medical advice in seeking treatment because of something you have read here or anywhere online. If you think you may have a medical emergency, immediately call your doctor or dial 911. |