Gut Health Quiz
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First Name
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Last Name
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Primary Email
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Have you experienced these symptoms?
Please rate these symptoms: 0-never, 1-mild, 2-regularly, 3-severe/often
Cravings for sugar, bread or alcohol:
Headaches:
Abdominal gas/flatulence:
Abdominal bloating:
Repeated bladder or kidney infection:
Increased food or chemical sensitivities:
Chronic diarrhea:
Constipation:
Hives, psoriasis, acne, skin rashes:
Rectal itching:
Muscle aches:
Joint aches:
Sleep Symptoms:
Insomnia:
Difficulty falling asleep:
Waking up during the night:
Mental Health Symptoms:
Brain fog:
Panic attacks:
Inability to concentrate:
Lethargy/apathy:
Low mood:
Irritable/loses temper easily:
ADD or ADHD symptoms:
Mood swings:
How is your energy on a scale of 1-10? (1 very low, 10 high)
Have you taken antibiotics in the last 6 months?
Make a selection
Yes
No
Have had in the last year
Do you have any food allergies or sensitivities?
Is your skin sensitive to beauty products or household cleaning products?
Do you have an autoimmune disorder/ disease?
Submit