Gut Health Assessment

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You can only select one answer. Answer to the best of your ability based on your current health concerns. During your consultations we can discuss any other issues and whether or not you have inflammation caused by issuies in your gut.

I have spent an extended amount of time:*

Exposed to toxins (amalgam fillings, mold etc.)
On an antibiotic or birth control pills
Cravings processed foods and sugary desserts
Addicted to caffeine drinks or coffee
Taking a pill or acid reflux or bloating
I don't relate to any of these

When it comes to my family, job & relationships:*

I am a "worry wart" & I seem to say "yes" to everyone
I often feel insecure, lack of confidence and grief
My schedule is very stressful and demanding causing strain on my relationships
I am driven to achieve but often focus too much on myself rather than others
I don't relate to any of these

I'm embarrased that I have issues with:*

Fungal issues (toe fungus, yeast infections, etc.)
Thinning hair or hair loss, decreased libido
Skin issues (eczema, psoriasis)
Burping & gas
Constipation
I don't relate to any of these

In conflict, this best describes me & my emotions:*

I often overreact and get into dramatic fights b/c of my emotions
Perfectionist tendencies, commitment to doing what I believe is "right"
Anxiety & Depression have been constant struggles
Exhausted from analyzing every aspect of a situation & get caught up on empathy for others
Store unforgiveness
I don't relate to any of these

I have seen the doctor with concern about my:*

Colon or Lungs
Spleen or intestinal issues
Gallbladder, gallstones or liver
Heart (high blood pressure or heart disease)
Adrenals, Thyroid or Kidneys
I don't relate to any of these

My main reason for looking into this gut program/intolerance testing relates to my issues with:*

Food sensitivities to things such as wheat, milk and eggs
Hormonal imbalance such as thyroid or adrenal issues such as adrenal fatigue
Acid reflux & digestion issues
Gallstones, gallbladder issues or have had my gallbladder removed
Bloating, diarrhea and yeast infections
I don't relate to any of these

My food/snack weakness is:*

COFFEE, COFFEE, COFFEE
Ice cream
Pasta & Cookies
Meat & high fat foods
French fries and burgers
I don't relate to any of these

My main health issues and concerns include:*

Autoimmune disease (Chrohns, IBS, etc.)
Frequent yeast infections or white coating on my tongue
Gallbladder & liver issues
Hypothyroidism, sluggish thyroid or adrenal fatigue
Acid reflux & SIBO
I don't relate to any of these

What emotions or life events have you experienced the most in the last year?*

Negative emotions
Depression
Deep grief or trauma
Loss of love or great disappointment in a relationshop
Held a grudge; struggle to forgive
I don't relate to any of these

What are the biggest emotions you experience when something doesn't go your way or you face adversity?*

Frustration & Anger
Worry & Anxiety
Overreact or heightened emotional response
Upset, depressed
Overwhelmed, stressed, exhausted
I don't relate to any of these

When it comes to eating, I tend to:*

Consume high amounts of sugary foods and caffeine weekly
Crave high-sugar foods and refined grains
Consume cold foods and drinks like salad, smoothies and ice water
Devour food, both eating too quickly and eating too much
Consume lots of hydrogenated fats (fried foods, store-bought cookies, etc.) and simple carbohydrates (break, pasta, candy, etc.)
I don't relate to any of these.

Most days I struggle with:*

Morning fatigue/trouble waking up
Brain fog (lack of focus & difficulty staying on task)
Inflammation & allergies
Overeating or needing an antacid
Temptation of high fat foods
I don't relate to any of these

More than once a week I experience:*

Indigestion or acid reflux
Digestive issues such as diarrhea or constipaton
Exhaustion, even when I get enough sleep
White coating on my tongue after consuming carbohydrates
Skin issues such as dry skin, acne, eczema or psoriasis
I don't relate to any of these

I currently am struggling most with:*

White coating on my tongue after meals
Bloating & Gas after meals
Chronic Issues (Lupus, Hashimotos, Rheumatoid Arthritis, Lupus, etc.)
Digesting Fats & Gallbladder issues
Fatigue & Weight Gain
I don't relate to any of these

Eating often looks like or includes:*

Cold Foods (ice water, cold smoothies or frozen treats)
Food "on the go" (I often eat quickly and may overeat)
High fat & processed foods
Coffee & caffeine
Food sensitivities (gluten, dairy, etc.)
I don't relate to any of these

Are you currently taking any prescription medications or over-the-counter drugs like asprin or ibuprofen?*

Do you have thyroid issues or sluggish metabolism?*

Do you have low energy or frequent fatigue?*

Do you have frequent diarrhea or loose stools?*

Do you have gas, bloating, or any other digestive issues more than once a week?*

Have you been diagnosed with an autoimmune disease?*

Do you struggle with seasonal allergies?*

Do you get sick often, meaning tow or more times a year, and do you feel like you need an immune system boost?*

Do you every go more than one day without a bowel movement?*

Do you have skin conditions like rosacea, eczema, acne, or rashes?*

Do you struggle with depression, anxiety, or lack of focus?*

Have you ever struggled with any type of candida, yeast, or fungal issues, or do you have a white coating on your tongue?*

Have you ever been diagnosed with ulcerative colitis, Crohn's disease, or IBS?*

Do you suffer from any type of pain, including joint pain or headaches?*

Are you sensitive to gluten or dairy?*

Do you have multiple food sensitivities or food allergies (other than gluten or dairy)?*

Do you have Hashimoto's thyroiditis, psoriasis, or multiple sclerosis?*

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Do you have Signs or Symptoms of Inflammation?