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Gut Health / Microbiome
Performance Optimization
Nutrition & Health
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Questionnaire
Name
Email
There are many causes for each symptom listed below. One of the most common causes is the presence of parasites. Please click the appropriate number next to each question.
A= symptom never occurs
B= symptom occurs occasionally
C= symptom occurs often
D= symptom occurs most of the time
Name
A
B
C
D
1.Chronic fatigue for no apparent reason
0
1
2
3
2.Swollen or achy joints
0
1
2
3
3.Increased appetite,hungry after meals
0
1
2
3
4.Eat out at restaurants
0
1
2
3
5.Nervous or irritable
0
1
2
3
6.Restless sleep/teeth grinding while asleep
0
1
2
3
7.Night sweats
0
1
2
3
8.Blurry, unclear vision
0
1
2
3
9.Fevers of unknown origin
0
1
2
3
10.Frequent colds, flu, sore throats
0
1
2
3
11.Recurrent feelings of unwellness
0
1
2
3
12.Constipation
0
1
2
3
13.Diarrhea alternating with constipation
0
1
2
3
14.Thinning or loss of hair
0
1
2
3
15.Allergies, food sensitivities
0
2
4
6
16.Irritable bowel, irregular bowel
0
2
4
6
17.Rectal, anal itching
0
2
4
6
18.Bloating or gas
0
2
4
6
19.Abdominal or liver pain/cramps
0
2
4
6
20.Mucus in nose that is moist or encrusted
0
2
4
6
21.Dark circles under the eyes
0
2
3
4
22.Bowel urgency
0
2
3
4
23.Skin problems, rashes, hives, itchy skin
0
2
3
4
24.Vertical wrinkles around mouth
0
2
3
4
25.Kiss pets, allow pets to lick your face
0
2
3
4
26.Go barefoot outside the home
0
2
3
4
27.Travel in 3rd world countries
0
2
3
4
28.Eat lightly cooked pork/ salmon products
0
2
3
4
29.Eat sushi, sashimi
0
2
3
4
30.Swim in creeks, rivers, lakes
0
2
3
4
31.History of parasitic infection
0
2
3
4
32.Loose stools or diarrhea
0
2
3
4
33.Pale, anemic or yellowish skin
0
2
3
4
34.Foul-smelling stools
0
2
3
4
35.Low back or kidney pain
0
2
3
4
36.Indigestion, malabsorption
0
2
3
4
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