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About
On Your Mark Nutrition
Precision Dietetics & Nutrition
Concierge Nutrition
Sport Performance
Functional Nutrition
Investigative Nutrition
Testimonials
Frequently Asked Questions
Policies
Team
Katie Mark
Dr. Lorenzo Gonzalez
Concierge Services
Sport Performance Nutrition
Functional Nutrition for Fitness, Health & Wellness
Investigative Nutrition
Testing
Education
Blog
Guest Articles
Guest Blogs
Tufts Nutrition
Contact
Client Login
Gut Health Questionnaire
Gut Health questionnaire
Name
*
First Name
Last Name
IMPAIRED MOTILITY
Autoimmunity
Have you had a case of gastroenteritis/food poisoning/traveler's diarrhea lasting for longer than 24 hours?
*
Yes
No
Do you have an autoimmune condition?
*
Yes
No
Do you have a family history of autoimmunity?
*
Yes
No
If Yes to either above, please explain:
Traumatic Brain Injury (TBI)
Have you had an injury to the head/spine or whiplash?
*
None
Bike Accident
Car Accident
Horse Riding Accident
Sporting Injury
Other
If Yes, please explain:
Have you ever suffered a concussion?
*
Yes
No
If Yes, please explain:
Have you ever lost consciousness?
*
Yes
No
If Yes, please explain:
Have you ever fallen on your coccyx/tailbone?
*
Yes
No
If Yes, please explain:
Thyroid Disorders
Have you ever been diagnosed with a thyroid disorder?
*
Yes
No
Are you on thyroid medication?
*
Yes
No
If Yes, please explain:
Diabetes
Have you ever been told you have metabolic syndrome, pre-diabetes or diabetes?
*
Yes
No
If Yes, please explain:
Infections
Do you have a history of chronic antibiotic use?
*
Yes
No
When did you have chronic antibiotic use?
Childhood
Teen
Adult
If Yes, please explain:
Have you ever been diagnosed with any of the following?
*
None
Chronic Fatigue Syndrome
Chronic Viral Illness
Fibromyalga
Lyme Disease
Have you been ill after a tick bite?
*
Yes
No
Are you allergic to red meat?
*
Yes
No
Mold Toxicity
Are you sensitive to mold?
*
Yes
No
Do you have mold in your home?
*
Yes
No
Have you ever lived in a moldy home and have not felt well since?
*
Yes
No
Hypermobility Disorder
Have you ever been diagnosed with Ehler's Danlos Syndrome (EDS) or hypermobility syndrome?
*
Yes
No
Are you double jointed?
*
Yes
No
IMPAIRED DIGESTION
Do you experience belching or gas within one hour after eating?
*
No
Mild
Moderate
Severe
Do you suffer from heartburn or acid reflux?
*
No
Mild
Moderate
Severe
Do you have bad breath?
*
No
Mild
Moderate
Severe
Do you have trouble digesting meat?
*
No
Mild
Moderate
Severe
Do you experience a sense of excessive fullness after meals?
*
No
Mild
Moderate
Severe
Do you experience stomach pain or cramping?
*
No
Mild
Moderate
Severe
Do you often see undigested food in your stool?
*
No
Mild
Moderate
Severe
Do your stools appear greasy or difficult to flush?
*
No
Mild
Moderate
Severe
Do you, or have you, experienced ongoing high levels of stress and/or anxiety?
*
Yes
No
Rate your current level of stress/anxiety from 1-10, with 1 equalling no stress/anxiety, and 10 equalling extreme stress/anxiety?
*
1
2
3
4
5
6
7
8
9
10
Please explain your answers to any above:
IMPAIRED OUTFLOW
Do you have a history of any abdominal surgeries such as:
*
None
Removal of Appendix
Removal of Gall Bladder
Hernia Repair
Other
If Yes, please explain:
Do you have a history of gynecological issues or surgeries? (e.g., endometriosis, hysterectomy, caesarean, pelvic inflammatory disease, ruptured ovarian cysts, laparoscopy)
*
Yes
No
Have you ever been diagnosed with any anatomical abnormalities of your digestive tract? (e.g., blind loops, diverticulitis, superior mesenteric artery syndrome)
*
Yes
No
If Yes to any above, please explain:
MEDICATIONS
What medications are you currently taking?
*
What medications have you taken in the past?
*
Please provide any additional information you feel may be helpful.
The above answers have been answered correctly and truthfully to the best of my knowledge.
*
Yes
Thank you!
