Gastrointestinal & Digestive Lifestyle Questionnaire
Is aimed at assessing lifestyle and Gastrointestinal health. The answers can help a person identify problem areas and target treatment accordingly.
Please mark any of the following that you eat regularly.
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How many drinks per week?
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Do you cook meals at home from scratch?
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How many total meals do you eat at home each week?
How many meals per week do you eat out?
Describe your current diet:
How many hours a day are you inactive or sitting?
How many times do you exercise per week?
And for how long per session?
Do you sweat when you exercise?
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How many hours of sleep do you get each night?
Do you feel rested when you wake up in the morning?
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Are you currently experiencing high levels of stress?
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Please rank the amount of stress from 1-10 with 1 being none and 10 being very much.
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Part 2 of this Questionnaire will help you identify which parts of the digestive tract are causing the most problems or symptoms.
Please enter the number that best describes the severity of the symptoms listed below. If you do not know the answer then leave it blank. Then add up the totals of the numbers and decide which areas need the most attention.
1 = Sometimes occurs with mild severity
2 - Occurs often with moderate severity
3 = Severe and always occurs
Section 1: LOW STOMACH ACID
Fullness for extended times after meals
Nausea after taking supplements or eating
Tested positive for candida or parasites
TOTAL: - 0-4 Low Priority - 5-9 Moderate Priority - 10 or above High Priority
Section 2: IMPROPER FUNCTION OF THE PANCREAS/SMALL INTESTINE
Having a difficult time gaining weight
Skin issues or acne (not around jawline)
Slimy stool or mucus in stool
Vegetables and fibre cause constipation
Alternating constipation and diarrhoea
Autoimmune condition(s) present
3 or more large bowel movements per day
Chronic stomach pain on left side below ribs
Excessively smelly stools
Undigested food in the stool
Gallbladder disease or history of gallstones
Acid reflux / heartburn / GERD
TOTAL: - 0-6 Low Priority - 6-10 Moderate Priority - 10 or above High Priority
Sourness tastes in mouth regularly
Coughing in the middle of the night
Have a hard time swallowing food and/or liquids
Constant burping, especially after meals
Regurgitating undigested food into the mouth
Burning in the stomach when eating citrus
TOTAL: - 0-3 Low Priority - 4-6 Moderate Priority - 7 or above High Priority
Section 4: TOO MUCH STOMACH ACID OR POSSIBLE ULCER(S)
Previous use of aspirin or NSAIDS
Black stool (and not taking iron supplements)
History of previous ulcer(s)
Family history or ulcers or gastritis
Stomach pain relieved by drinking dairy
Carbonated drinks temporarily relieve pain
Frequent burping and bloating
Regular butterflies in the stomach feeling
Antacids required for heartburn and/or acid reflux
Pain in the stomach before meals
Pain in stomach occurs when stressed or upset
TOTAL: - 0-4 Low Priority - 5-8 Moderate Priority - 9 or above High Priority
Section 5: GALLBLADDER AND LIVER DYSFUNCTION
Have a hard time gaining weight
Yellowish tint in the whites of the eyes
Not having a daily bowel movement
Pain felt or radiating on the outside of the leg
Have had jaundice or hepatitis (No = 0, more than 2 years ago = 1, Current = 2, Chronic = 3)
Blood in the stool (reddish colour) (No = 0, More than 2 years ago = 1, Current = 2, Chronic = 3)
Triglyceride level above 115 (No = 0, Unknown = Blank, Yes = 2)
Migraines or headaches after eating
Intolerance to greasy foods
Pain in the right side under the rib
High blood cholesterol and low HDL (No = 0, Unknown = Blank, Yes = 2)
Cholesterol above 200 (No = 0, Unknown = Blank, Yes = 2)
TOTAL: - 0-5 Low Priority - 5-9 Moderate Priority - 10 or above High Priority
Section 6: DYSBIOSIS OR BACTERIAL OVERGROWTH
Have food sensitivities/intolerances
Have acid reflux or heartburn
Have a vitamin D deficiency
Have arthritis or fibromyalgia
Taken antibiotics more than twice in the past year
Have trouble digesting beans and fibre
Have trouble digesting carbohydrates
Depressed or anxious all the time
Have cramps after you eat
Have mucus or blood in your stool
Diagnosed with an autoimmune disease or condition
TOTAL: - 1-5 Low Priority - 6-10 Mild Priority - 7-19 Moderate Priority - 20 or above High Priority
Section 7: POSSIBLE SMALL INTESTINE BACTERIAL OVERGROWTH (SIBO)
Currently taking antacids or proton pump inhibitors for heartburn or GERD
Intolerance to probiotic supplements and prebiotic fibres
Abdominal bloating and distension, especially with carbohydrates such as sugar & fibre
Irritable bowel syndrome (IBS)
Scored 9 or more on the Low Stomach Acid section
TOTAL: - 0-4 Low Priority - 5-9 Moderate Priority - 10 or above High Priority
Section 8: LOW DIGESTIVE ENZYME PRODUCTION
Take antacids or acid blocking medication
Have food sensitivities/intolerances
Bruise easily (Can also be low vitamin K)
Does not have a daily bowel movement
Have foul smelling stools
Belching or flatulence after eating
Abdominal bloating or swelling
Undigested food in the stool
Signs of poor digestion of fatty foods
Weak, peeling or cracked fingernails
Fatigue in spite of a good diet and regular sleep
Inability to gain muscle despite weight training
Chewing your food properly
TOTAL: - 0-6 Low Priority - 6-10 Moderate Priority - 10 or above High Priority
Section 9: LEAKY GUT OR INTESTINAL PERMIABILITY
Chronic sinus or nasal congestion
History of antibiotic use
Chronic and frequent inflammation
Chronic or frequent fatigue or tiredness
Mucus or blood in the stool
Constipation and/or diarrhoea
Eczema, skin conditions or hives
Ulcerative colitis, Chronic disease or Celiac disease
Use or nonsteroidal anti-inflammatory drugs (Aspirin, Ibuprofen)
Asthma, hay fever or airbourne allergies
Food allergy or food intolerances
Joint pain/swelling/arthritis
Abdominal pain or bloating
Confusion/poor memory/mood swings
TOTAL: - 1-5 Low Priority - 6-10 Mild priority - 7-19 Moderate Priority - 20 or above High Priority
Section 10: GLUTEN SENSITIVITY
Achy joints or chronic joint pain
Anaemic or iron deficiency anaemia
Have a hard time losing weight
Constipation and/or diarrhoea
Osteoporosis or osteopenia
History of family of cancer
History of family history of arthritis
History of family history of autoimmune disease
History of family history of celiac disease
TOTAL: - 0-6 Low Priority - 6-10 Moderate Priority - 10 or above High Priority
Section 11: LARGE INTESTINE OR COLON PROBLEMS
Family history of inflammatory Bowel Disease
Blood or pus in the stool
History of antibiotic use
Vaginal yeast infections or oral thrush
Bladder and kidney infections
Frequent and recurrent infections
Seasonal or recurring diarrhoea
Alternating diarrhoea and constipation
Toe and fingernail fungus
TOTAL: - 0-5 Low Priority - 6-9 Moderate Priority - 10 or above High Priority
