1. Do you have frequent bloating, gas, or abdominal discomfort?
*
0 = Never
1 = Rarely (1-2x/month)
2 = Occassionally (1x/week or less)
3 = Often (2-3x/week)
4 = Very Frequently (daily or almost daily)
2. Have you had a history of food poisoning or travel-related digestive illness?
*
0 = Never
2 = Unsure
4 = Yes
3. Do you have unexplained fatigue that comes and goes or worsens after eating?
*
0 = Never
1 = Rarely (1-2x/month)
2 = Occassionally (1x/week or less)
3 = Often (2-3x/week)
4 = Very Frequently (daily or almost daily)
4. Do you experience anal itching, vivid dreams or teeth grinding at night?
*
0 = Never
2 = Occassionally
4 = Frequently
5. Do you eat sushi, raw/rare meat, or unwashed produce regularly?
*
0 = Never
1 = Rarely (1-2x/month)
2 = Occassionally (1x/week or less)
3 = Often (2-3x/week)
4 = Very Frequently (daily or almost daily)
6. Do you have skin rashes, hives, eczema or itching without a clear cause?
*
0 = Never
1 = Rarely (1-2x/month)
2 = Occassionally (1x/week or less)
3 = Often (2-3x/week)
4 = Very Frequently (daily or almost daily)
7. Do you experience mood swings, irritability, anxiety, or brain fog that fluctuates without cause? (unrelated to life events)
*
0 = Never
1 = Rarely (1-2x/month)
2 = Occassionally (1x/week or less)
3 = Often (2-3x/week)
4 = Very Frequently (daily or almost daily)
8. Have you taken antibiotics, PPIs, or corticosteroids for longer than 2 weeks in the past? (or currently)
*
0 = Never
4 = Yes
9. Do you have frequent diarrhoea, constipation, or alternating bowel habits?
*
0 = Never
1 = Rarely (1-2x/month)
2 = Occassionally (1x/week or less)
3 = Often (2-3x/week)
4 = Very Frequently (daily or almost daily)
10. Do you feel 'hangry', experience sugar cravings, or find yourself needing frequent snacks?
*
0 = Never
1 = Rarely (1-2x/month)
2 = Occassionally (1x/week or less)
3 = Often (2-3x/week)
4 = Very Frequently (daily or almost daily)
11. Do you have pets that lick your face, sleep in your bed, or go outdoors?
*
0 = Never
1 = Rarely (1-2x/month)
2 = Occassionally (1x/week or less)
3 = Often (2-3x/week)
4 = Very Frequently (daily or almost daily)
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*
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Last Name
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