Functional Health Diagnostics

Digestion Questionaire

Colon Health Questionaire

Select "Yes", or "No"
OR
The number that best reflects the intensity of each statement.
Never,
Seldom,
Occasional,
Often

Name & Surname

High Acidity

1.	Stomach pains just before or after meals	Never Seldom Occasional Often
2.	Stomach pains with no apparent reason	Never Seldom Occasional Often
3.	Stomach pain relieved by carbonated drinks	Never Seldom Occasional Often
4.	Stomach pain relieved by milk/cream	Never Seldom Occasional Often
5.	Emotional upset causes stomach pain	Never Seldom Occasional Often
6.	Heartburn immediately after meals	Never Seldom Occasional Often
7.	Constant need for antacids	Never Seldom Occasional Often
8.	"Butterfly feeling" in stomach	Never Seldom Occasional Often
9.	Family history of ulcer/gastritis?	No Yes
10.	Ulcer in the past year?	No Yes
11.	Current ulcer?	No Yes
12.	Very dark or black stool?	No Yes
13.	Hot/spicy food causes stomach irritation?	No Yes

Low Acidity

1.	Indigestion	Never Seldom Occasional Often
2.	Abdominal bloating	Never Seldom Occasional Often
3.	Feel too full after eating	Never Seldom Occasional Often
4.	Constipation	Never Seldom Occasional Often
5.	Belching/Burping	Never Seldom Occasional Often
6.	Diminished appetite	Never Seldom Occasional Often
7.	Stomach growls/gurgles	Never Seldom Occasional Often
8.	Any known food allergies?	No Yes