Heart_nerve Questionnaire
SIBO is the cause of many gastro-intestinal distresses, as well as symptoms throughout the body due to inflammation and immune compromise. It often has a neurological and immunological connection. It can cause digestive tract issues to rule a person's life. A breath test can identify some species-hydrogen sulfide and methane producers-but not all. This questionnaire covers a wide gamut of symptoms that can have SIBO as a cause or contributor.

The fields denoted with * are compulsory fields

* Name & Surname
* Telephone
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For each statement that applies to you, enter a ' X '.

1.
Abdominal cramping due to indigestion?
2.
Abdominal bloating, distention?
3.
Abdominal pain comes and goes, often with eating?
4.
Antibiotic(s) used in past 10 years, or frequently as child?
5.
Antibiotic use temporarily relieves stomach/intestinal symptoms?
6.
Bad breath not resolved by oral hygiene support?
7.
Birth Control Pills, ever used?
8.
Bowel urgency, occasional accidents?
9.
Brain fog / Poor memory?
10.
Breast fed: Not breast fed as an infant?
11.
Burping (Belching) after meals?
12.
Celiac disease, wheat/gluten sensitivity?
13.
Constipation? Hard, dry stools, pellets, balls?
14.
Dairy products (milk) aggravates (constipates or loosens stool)?
15.
Diarrhea, loose stools frequent? Or alternates with constipation?
16.
Fiber supplements cause bloating or constipation?
17.
Fibromyalgia / Chronic Fatigue Syndrome?
18.
Flatulence (frequent gas)?
19.
GERD (Gastro-Esophageal Reflux Disorder) / Heartburn?
20.
Hypothyroid?
21.
IBS (Irritable Bowel Syndrome), or Crohn's Disease?
22.
Lactose intolerance?
23.
Leaky Gut Syndrome?
24.
Morphine, Opiates, Hydrocodone medications: ever used?
25.
Prebiotics (Fructooligosaccharides-FOS) cause pain, bloating, cramping?
26.
Skin disorders: Eczema, Psoriasis, Rosacea
27.
Sugar starch grain cravings?
28.
Traveler's diarrhea, food poisoning: never felt quite right since?
29.
Ulcerative colitis?
30.
Vitamin/Mineral insufficiencies: Vitamin B12, Vitamin D3, Ferritin-Iron