Name & Surname

Select "No", "Sometimes" or "Yes"

Condition

1.

Diarrhea?

No

Sometimes

Yes

2.

Recurrent infections or colds?

No

Sometimes

Yes

3.

History if kidney/bladder infections?

No

Sometimes

Yes

4.

Yeast Infections (Vaginal yeast)?

No

Sometimes

Yes

5.

Frequent abdominal cramps?

No

Sometimes

Yes

6.

Fingernail/toenail fungus?

No

Sometimes

Yes

7.

Diarrhea and constipation alternate?

No

Sometimes

Yes

8.

Chronic constipation (less than 2 BMs/day)?

No

Sometimes

Yes

9.

Used antibiotics in past year?

No

Sometimes

Yes

10.

Very few vegetables in diet?

No

Sometimes

Yes

11.

Vision rapidly deteriorating?

No

Sometimes

Yes

12.

Stool has foul odor?

No

Sometimes

Yes

13.

Frequent gas?

No

Sometimes

Yes

14.

Restless sleep?

No

Sometimes

Yes

15.

Rectal, anal itch?

No

Sometimes

Yes

16.

Sexual dysfunction?

No

Sometimes

Yes

17.

Slow reflexes?

No

Sometimes

Yes

18.

Pain, back thighs, shoulders?

No

Sometimes

Yes

19.

Lethargy, fatigue, apathy?

No

Sometimes

Yes

20.

Numbness, tingling in hands, feet?

No

Sometimes

Yes

21.

Drink chlorinated or fluoridated water?

No

Sometimes

Yes

22.

Bloating after eating or drinking

No

Sometimes

Yes

23.

Mucous in stool?

No

Sometimes

Yes

24.

Need laxatives to maintain regularity?

No

Sometimes

Yes