NAME:
DOB:
ACCT #
Leaky Gut Wellness Evaluation
Many health issues related to Leaky Gut Syndrome go undiagnosed, misdiagnosed, or are ignored by traditional medicine. Please complete this eval to help our doctors determine how we can help and underlying conditions that may limit the healing process.
Please circle any that apply to you prior to completing the lower questionnaire and print form.
Sub-clinical symptoms including:
Headaches and Migraines
Hormone imbalance including:
PMS / emotional imbalance
Gastrointestinal issue including:
Abdominal bloating and cramps or painful gas
Irritable Bowel Syndrome
Ulcerative Colitis
Crohn’s Disease and other intestinal disorders
Respiratory conditions including:
Chronic sinusitis
Asthma
Allergies
Autoimmune conditions including:
Diabetes Mellitus
Lupus
Rheumatoid Arthritis
Fibromyalgia
Chronic Fatigue
Developmental and Social concerns including:
Autism
ADD/ ADAHD
Skin conditions: (urticaria)
Eczema
Skin Rashes
Hives
Heart Conditions including:
High Cholesterol
High Blood Pressure
Do you experience acid reflux more than 1x/ week? Yes No
Do you have a white coating on your tongue after consuming carbohydrates? Yes No
Leaky Gut Questionnaire
Constipation and/or diarrhea
Abdominal pain or bloating
Mucous or blood in stool
Joint pain or swelling, arthritis
Chronic or frequent fatigue / tiredness
Food allergies, sensitivities, or intolerance
Sinus or nasal congestion
Chronic or frequent inflammation
Eczema, skin rashes, or hives
Asthma, hay fever, or airborne allergies
Confusion, poor memory, or mood swings
Use of NSAIDS (Aspirin, Tylenol, Motrin)
History of antibiotic use
Alcohol consumption makes you feel sick
Ulcerative colitis or celiac’s disease
Nausea
Weight Trouble
Anxiety / Depression
None
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Please Total Your Score:
Mild
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Please Total Your Score:
Constipation and/or diarrhea
Abdominal pain or bloating
Mucous or blood in stool
Joint pain or swelling, arthritis
Chronic or frequent fatigue / tiredness
Food allergies, sensitivities, or intolerance
Sinus or nasal congestion
Chronic or frequent inflammation
Eczema, skin rashes, or hives
Asthma, hay fever, or airborne allergies
Confusion, poor memory, or mood swings
Use of NSAIDS (Aspirin, Tylenol, Motrin)
History of antibiotic use
Alcohol consumption makes you feel sick
Ulcerative colitis or celiac’s disease
Nausea
Weight Trouble
Anxiety / Depression
Moderate
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Please Total Your Score:
Severe
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
Please Total Your Score: