Bowel Health Quest





Please fill in your best response and then we will get back to you shortly with some advice on how we can help you.

Never/No Sometimes Always/Yes
1. Do you have excessive burping and belching?
2. Do you get a feeling of fullness after /during eating?
3. Do you have bad breath?
4. Do you have abdominal pain/cramping?
5. Do you have abdominal bloating?
6. Do you have lots of gas and offensive wind?
7. Do you feel sick in the stomach?
8. Do you get heartburn?
9. Is it worse when you lie down /bend over from the waist?
10. Does it feel better when you take antacids/drink milk/cream?
11. Do you suffer alternate bouts of constipation/diarrhea?
12. Do you move your bowels daily?
13. Do you move your bowels 2-3 times a week?
14. Do you move your bowels less than 3 times a week?
15. Do you have difficulty passing stool- straining/ pushing?
16. Does it take you more than 5 minutes to eliminate?
17. Do you take laxatives – pills/ suppositories/ teas etc?
18. Is your stool hard/dry/small?
19. Have you seen mucus / blood in your stool?
20. Do you see bright red blood on the paper on wiping?
21. Is your stool black/ tarry?
22. Have you lost weight without reason?
23. Do you have painful bowel movements?
24. Do you eliminate completely, or feel there is often something left?
25. Do you have rectal pain before /after a motion?
26. Do you have anal itching?
27. Are you irritable and moody?
28. Do you sleep well – at least 8 hours per night, undisturbed?
29. Do you suffer from allergies / sinus problems?
30. Do you get headaches?
31. Do you have memory lapses/ problems concentrating?
32. Do you suffer from athlete’s foot/tinea/nail fungus?
33. Do you lack energy in the afternoon/ after eating a meal?
34. Are you vegetarian?
35. Do you eat meat, sausages, processed meats?
36. Do you eat take a-ways/fried foods, sugars (including chocolate) more than 3 times a week?
37. Do you drink at least 1 ½ L of purified water a day?
38. Do you exercise at least 30 mins 3-4 times a week?
39. Do you currently suffer with health problems?
40. Are you unhappy with your current state of health?




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