Gut Health Assessment

1
Name* This field is required.
First Name
Last Name
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E-mail* This field is required.
example@example.com
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Gender
Male
Female
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Phone Number* This field is required.
Area Code
Phone Number
5
Birth History
Was born by C-section
Was not breastfed as an infant
6
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
Other
7
Lifestyle
I have stress from work, school, finances, emotions etc in my life
I get less than 8 hours sleep per night
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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
Other
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Infections
I am frequently ill
I have candida (yeast) overgrowth
I have parasites
I have small intestinal bacterial overgrowth (SIBO)
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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
11
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
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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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Skin
Acne
Skin rashes
Eczema
Hives
Rosacea
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MIND / EMOTIONS
Anxiety
Depression
Mood Swings
Brain fog
Difficulty concentrating / focusing / poor memory
ADD / ADHD
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HORMONAL IMBALANCES
Irregular periods
PCOS
PMS
Painful periods
Infertility
Fibroids
Endometriosis
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DIGESTIVE TRACT
Belching
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
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JOINT/MUSCLE
Arthritis
Joint Pain
Joint Swelling
Fibromyalgia
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HEAD / NOSE / LUNGS
Asthma
Congestion
Dizziness
Headaches
Migraines
Stuffy Nose
Seasonal allergies
Other
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ENERGY / SLEEP
Fatigue / Chronic Fatigue Syndrome
Low energy
Insomnia
Sleep disturbance
Other
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IMMUNE / OTHER
Low WBC count
Autoimmune disease
Cancer
Diabetes
Frequent illness
Thyroid imbalance
Weight gain
Other
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Here's your score and see where your gut health ranks!
1-3 Mildly Leaky | 3-10 Moderately Leaky | 10 or More Severely
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Use your score from Previous Page and See Where Your Gut Health Ranks* This field is required.Check the Total Score From the Previous Tile
1-3 MILDY 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 a leaky gut. You would benefit from gut-healing supplements and our Gut Health Program for 2 months.
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