Digestive Health Questionnaires

Performance Training Center does

Strength, Power and Performance Conditioning.

Comprehensive Structural Assessments and Program Designs.

Corrective and Restorative Exercise.

Nutrition

Hypoacidity of the Stomach
1	Burping	0 1 2 3
2	Fullness for extended time after meals	0 1 2 3
3	Bloting	0 1 2 3
4	Poor appetite	0 1 2 3
5	Stomach upsets easily	0 1 2 3
6	History of contipation	0 1 2 3
7	Known food allergies	0 1 2 3
Total

Ulcer/ Hyperacidity of the Stomach
1	Stomach Pains	0 1 2 3
2	Stomach pains just before or after meals	0 1 2 3
3	Dependancy on antacids	0 1 2 3
4	Chronic abdominal pains	0 1 2 3
5	Butterfly sensations in stomach	0 1 2 3
6	Difficulty belching	0 1 2 3
7	Stomach pain when emotionally upset	0 1 2 3
8	Sudden, acute indigestion	0 1 2 3
8	Sudden, acute indigestion	0 1 2 3
9	Relief of symptoms by carbonated drinks	0 1 2 3
10	Relief of stomach pain by drinking cream/milk	0 1 2 3
11	History of ulcer or gastritis	0 1 2 3
12	Current ulcer	0 1 2 3
13	Black stool when not taking Iron supplements	0 1 2 3
Total

Gastric Reflux
1	Sour taste in mouth	0 1 2 3
2	Regurgitate undigested food into mouth	0 1 2 3
3	Frequent nocturnal coughing	0 1 2 3
4	Burning sensation from citrus on way to stomach	0 1 2 3
5	Heartburn	0 1 2 3
6	Burping	0 1 2 3
7	Difficulty swallowing solids or liquids	0 1 2 3

Liver/ Gallbludder
1	Intolerance to greasy foods	0 1 2 3
2	Headaches after eating	0 1 2 3
3	Light coloured stool	0 1 2 3
4	Foul smelling stool	0 1 2 3
5	Less than bowel movement daily	0 1 2 3
6	Constipation	0 1 2 3
7	Hard stool	0 1 2 3
8	Sour taste in mouth	0 1 2 3
9	Grey coloured skin	0 1 2 3
10	Yellow in whites of eyes	0 1 2 3
11	Bad breath	0 1 2 3
12	Body odour	0 1 2 3
13	Fatigue and sleepiness after eating	0 1 2 3
14	Pain in right side under rib cage	0 1 2 3
15	Painful to pass stool	0 1 2 3
16	Retain water	0 1 2 3
17	Big toe painful	0 1 2 3
18	Pain radiates along outside of leg	0 1 2 3
19	Dry skin/hair	0 1 2 3
20	Red blood in stool	0 1 2 3
21	Have had jaundice or hepatitis	0 1 2 3
22	High blood cholesterol and HDL cholesterol	0 1 2 3
23	Is cholesterol level above 5.2	0 1 2 3
24	Is your tryglyceride level above 1.7	0 1 2 3

Hypofunction of Small Intestines and/or Pancreas
1	Abdominal cramps	0 1 2 3
2	Indigestion one to three hours after eating	0 1 2 3
3	Fatigue after eating	0 1 2 3
4	Lower bowel gas	0 1 2 3
5	Alternating constipation and diarrhea	0 1 2 3
6	Diarrhea	0 1 2 3
7	Roughage & fiber causes constipation	0 1 2 3
8	Mucus in stools	0 1 2 3
9	Stool poorly formed	0 1 2 3
10	Shiny stool	0 1 2 3
11	Three or more large bowel movements daily	0 1 2 3
12	Dry, Flaky skin and/or dry brittle hair	0 1 2 3
13	Pain in left side under rib cage	0 1 2 3
14	Acne	0 1 2 3
15	Food allergies	0 1 2 3
16	Difficulty gaining weight	0 1 2 3
17	Foul smelling stool	0 1 2 3

Intestinal Permeability/ Leaky Gut syndrome, Dysbiosis
1	Constipation and or diarrhea	0 1 2 3
2	Abdominal pain or bloating	0 1 2 3
3	Mucus or blood in stool	0 1 2 3
4	Joint pain or sweling or arthritis	0 1 2 3
5	Chronic or frequent fatigue or tiredness	0 1 2 3
6	Food allergy or food sensitivities or intolerance	0 1 2 3
7	Sinus or nasal congestion	0 1 2 3
8	Chronic or frequent inflammations	0 1 2 3
9	Eczema, skin rashes, or hives (urticarial)	0 1 2 3
10	Asthma, hayfever or airborne allergies	0 1 2 3
11	Confusion, poor memory or mood swings	0 1 2 3
12	Use of nonstroidal anti inflammatory drugs (aspirin, Tylenol, Motrin)	0 1 2 3
13	History of antibiotic use	0 1 2 3
14	Alcohol consumption, or alcohol makes you feel sick	0 1 2 3
15	Ulcerative colitis, crohn's disease, or cellac disease	0 1 2 3

Colon/ Large Intestine
1	Seasonal Diarrhea	0 1 2 3
2	Frequent and recurrent infections (colds)	0 1 2 3
3	Bladder and kidney infections	0 1 2 3
4	Vaginal yeast infection	0 1 2 3
5	Abdominal cramps	0 1 2 3
6	Toe and fingernail fungus	0 1 2 3
7	Alternating diahrrea/ constipation	0 1 2 3
8	Constipation	0 1 2 3
9	History of antibiotic use	0 1 2 3
10	Meat eater	0 1 2 3
11	Rapidly falling vision	0 1 2 3