Functional Health Diagnostics

Liver-Gall Bladder Health Questionaire

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

Name & Surname

High Acidity

1.	Abdominal pain after eating fatty foods	Never Seldom Occasional Often
2.	Pain in the side under right rib cage	Never Seldom Occasional Often
3.	Painful or tender big toe	Never Seldom Occasional Often
4.	Hard/dry stool (painful to pass)	Never Seldom Occasional Often
5.	Stool color is grayish (light in color)	Never Seldom Occasional Often
6.	Stool has foul odor	Never Seldom Occasional Often
7.	Less than one daily bowel movement	Never Seldom Occasional Often
8.	History of constipation	Never Seldom Occasional Often
9.	Gray colored skin	Never Seldom Occasional Often
10.	Headaches following meals	Never Seldom Occasional Often
11.	Recurring sour, bitter taste in mouth	Never Seldom Occasional Often
12.	Red blood in stool?	No Yes
13.	Yellow sclera (white of the eyes)	Never Seldom Occasional Often
14.	Bad breath or body odor	Never Seldom Occasional Often
15.	Tired/sleepy after meals	Never Seldom Occasional Often
16.	Dandruff	Never Seldom Occasional Often
17.	Retain water	Never Seldom Occasional Often
18.	Dry skin and/or hair	Never Seldom Occasional Often
19.	Eat at fast food restaurants	Never Seldom Occasional Often
20.	Impatient, impulsive, easy to anger	Never Seldom Occasional Often
21.	Vision problems/red or dry eyes?	No Yes
22.	Have had jaundice or hepatitis?	No Yes
23.	High blood cholesterol and/or low HDL?	No Yes