Embracing Health

Digestion Test Questionnaire

Step 1: Personal Details

Full Name DOB
Email Gender
Address Height
Weight
How did you find out about this testing service?
Consultation - Preferred Day Preferred Time Contact # for consultation
Medications, including over the counter antacids, laxatives etc
Supplements
Operations had, organs removed
Diagnosed with any specific disease or disorder

Step 2: Tick YES what's applicable to you. Not sure or Not applicable? Leave as is..
STOOL FREQUENCY
> 3 times per day  Y N Pale in colour  Y N
3 times per day  Y N Loose  Y N
2 times per day  Y N Watery, runny  Y N
Once per day  Y N Explosive  Y N
Every 2nd day  Y N Difficult  Y N
Twice per week  Y N Painful  Y N
Once per week  Y N Bad odour  Y N
SYMPTOMS
SIGNS
Bloating  Y N Weak, peeling fingernails  Y N
Burping  Y N Dry Skin  Y N
Flatulence  Y N Weak immune system  Y N
Indigestion  Y N Sugar cravings  Y N
Heartburn  Y N Anaemia (low iron)  Y N
Reflux  Y N Allergies  Y N
Urgency  Y N Sinus  Y N
Cramps  Y N Headaches  Y N
Haemorrhoids  Y N Weight loss  Y N
Itchy Anus  Y N
Nausea  Y N

Step 3 : Family History of:
Bad breath  Y N
STOOL DESCRIPTION Bowel cancer
Undigested Food  Y N Osteoporosis
Long & Thin  Y N Auto-immune disease
Sticky  Y N Coeliac Disease