Gut Health Assessment

Name *

First Name Last Name
E-mail *
example@example.com
Gender
Phone Number *

Area Code Phone Number
Birth History

Was born by C-section Was not breastfed as an infant
Medical History

A history of taking, or am currently taking antibiotics for an infection or acne Have a history of taking, or am currently taking prescription or over-the-counter medications for fever, headaches, pain, inflammation etc. Pancreatic insufficiency and/or liver disease Food allergies or intolerances Inflammation Chrohn’s disease, Cystic fibrosis, Celiac disease, Irritable Bowel Syndrome or Inflammatory Bowel Disease Seasonal allergies
Lifestyle

I have stress from work, school, finances, emotions etc in my life I get less than 8 hours sleep per night
Food

I eat gluten, dairy, eggs, yeast, corn or soy I consume non-GMO foods My diet includes added sugar, caffeine, and/or alcohol I eat processed/packaged foods 3+ times per week I eat fast food 1+ times per week I consume alcohol more than 2 drinks per week Artificial sweeteners/food dyes/preservatives/additives are present in my foods I drink unfiltered tap water or rain water I eat non-organic fruit and vegetables daily
Infections

I am frequently ill I have candida (yeast) overgrowth I have parasites I have small intestinal bacterial overgrowth (SIBO)
Medications - I have used the following in the past 6 months or have prolonged/regular use in my lifetime:

NSAIDS (non-steroidal anti-inflammatory drugs) eg: Aspirin Opioids (pain medication) Corticosteroids (Prednisone) Antibiotics Acid-reducing drugs Oral contraceptives Long term antibiotics
Toxins

I have been exposed to harmful chemicals such as pesticides, herbicides, heavy metals I dry clean my clothes frequently I have had lengthy exposure to moldy environments I consume peanuts and/or pistachios regularly Toxins (mercury, pesticides, BPA) eg mercury fillings I am a hairdresser I use mainstream personal care products, laundry powders, make up and skin care
Exercise

I do not exercise I am an extreme athlete who performs high intensity running or rigorous training I swim in chlorinated pools regularly
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Use this symptom checklist to determine if you have leaky gut syndrome.
SKIN
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Acne Skin rashes Eczema Hives Rosacea
MIND / EMOTIONS
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Anxiety Depression Mood Swings Brain fog Difficulty concentrating / focusing / poor memory ADD / ADHD
HORMONAL IMBALANCES
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Irregular periods PCOS PMS Painful periods Infertility Fibroids Endometriosis
DIGESTIVE TRACT
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Belching Bloating Constipation (less than 1-3 bowel movements per day) Diarrhea / loose stools / irritable bowel Nausea or vomiting Passing gas Foul smelling stool or gas Stomach pain Intestinal spasms Heartburn or acid reflux
JOINT/MUSCLE
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Arthritis Joint Pain Joint Swelling Fibromyalgia
HEAD / NOSE / LUNGS
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Asthma Congestion Dizziness Headaches Migraines Stuffy Nose Seasonal allergies
ENERGY / SLEEP
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Fatigue / Chronic Fatigue Syndrome Low energy Insomnia Sleep disturbance
IMMUNE / OTHER
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Low WBC count Autoimmune disease Cancer Diabetes Frequent illness Thyroid imbalance Weight gain
Tally your score and see where your gut health ranks!
1-3 Mildly Leaky

Your symptoms suggest that you have a mildly leaky gut.

I would recommend that you consider gut-healing supplements and try our Gut Health Program for 1 month.
3-10 Moderately Leaky

Your symptoms suggest a leaky gut.

You would benefit from gut-healing supplements and our Gut Health Program for 2 months.
10 or More Severely Leaky

Your symptoms suggest damage to your gut which could be severe. I am here to help you regain your health and vitality through a tailored leaky gut syndrome protocol of correct eating and supplementation for 3 or more months.
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