Colon Health Questionaire
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* Name & Surname
* Telephone
* Email
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
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