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Never/No |
Sometimes |
Always/Yes |
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| 1. |
Do you have excessive burping and belching? |
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| 2. |
Do you get a feeling of fullness after /during eating? |
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| 3. |
Do you have bad breath? |
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| 4. |
Abdominal pain/cramping? |
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| 5. |
Abdominal bloating? |
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| 6. |
Lots of gas and offensive wind? |
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| 7. |
A sick in the stomach feeling? |
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| 8. |
Do you get heartburn? |
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| 9. |
Is it worse when you lie down /bend over from the waist? |
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| 10. |
Does it feel better when you take antacids/ drink milk/ cream? |
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| 11. |
Do you suffer alternate bouts of constipation /diarrhoea? |
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| 12. |
Do you move your bowels daily? |
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| 13. |
Do you move your bowels 2-3 times a week? |
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| 14. |
Do you move your bowels less than 3 times a week? |
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| 15. |
Do you have difficulty passing stool- straining/ pushing? |
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| 16. |
Does it take you more than 5 minutes to eliminate? |
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| 17. |
Do you take laxatives – pills/ suppositories/ teas etc? |
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| 18. |
Is you stool hard/dry/small? |
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| 19. |
Have you seen mucus / blood in your stool? |
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| 20. |
Do you see bright red blood on the paper on wiping? |
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| 21. |
Is your stool black / tar like? |
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| 22. |
Have you lost weight without reason? |
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| 23. |
Do you have painful bowel movements? |
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| 24. |
Do you eliminate completely, or feel there is often something left? |
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| 25. |
Do you have rectal pain before /after a motion? |
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| 26. |
Do you have anal itching? |
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| 27. |
Are you irritable and moody? |
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| 28. |
Do you sleep well – at least 8 hours per night, undisturbed? |
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| 29. |
Do you suffer from allergies / sinus problems? |
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| 30. |
Do you get headaches? |
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| 31. |
Do you have memory lapses/ problems concentrating? |
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| 32. |
Do you suffer from athletes foot,/ tinea / nail fungus? |
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| 33. |
Do you lack energy in the afternoon/ after eating a meal? |
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| 34. |
Are you vegetarian? |
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| 35. |
Do you eat meat, sausages, processed meats? |
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| 36. |
Do you eat take a-ways/ fried foods, sugars (including chocolate) more than 3 times a week? |
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| 37. |
Do you drink at least 1 ½ L of purified water a day? |
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| 38. |
Do you exercise at least 30 mins 3-4 times a week? |
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| 39. |
Do you currently suffer with health problems? |
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| 40. |
Are you unhappy with your current state of health? |
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