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

    1. Do you have excessive burping and belching?
    Never/NoSometimesAlways/Yes
    2. Do you get a feeling of fullness after /during eating?
    Never/NoSometimesAlways/Yes
    3. Do you have bad breath?
    Never/NoSometimesAlways/Yes
    4. Do you have abdominal pain/cramping?
    Never/NoSometimesAlways/Yes
    5. Do you have abdominal bloating?
    Never/NoSometimesAlways/Yes
    6. Do you have lots of gas and offensive wind?
    Never/NoSometimesAlways/Yes
    7. Do you feel sick in the stomach?
    Never/NoSometimesAlways/Yes
    8. Do you get heartburn?
    Never/NoSometimesAlways/Yes
    9. Is it worse when you lie down /bend over from the waist?
    Never/NoSometimesAlways/Yes
    10. Does it feel better when you take antacids/drink milk/cream?
    Never/NoSometimesAlways/Yes
    11. Do you suffer alternate bouts of constipation/diarrhea?
    Never/NoSometimesAlways/Yes
    12. Do you move your bowels daily?
    Never/NoSometimesAlways/Yes
    13. Do you move your bowels 2-3 times a week?
    Never/NoSometimesAlways/Yes
    14. Do you move your bowels less than 3 times a week?
    Never/NoSometimesAlways/Yes
    15. Do you have difficulty passing stool- straining/ pushing?
    Never/NoSometimesAlways/Yes
    16. Does it take you more than 5 minutes to eliminate?
    Never/NoSometimesAlways/Yes
    17. Do you take laxatives – pills/ suppositories/ teas etc?
    Never/NoSometimesAlways/Yes
    18. Is your stool hard/dry/small?
    Never/NoSometimesAlways/Yes
    19. Have you seen mucus / blood in your stool?
    Never/NoSometimesAlways/Yes
    20. Do you see bright red blood on the paper on wiping?
    Never/NoSometimesAlways/Yes
    21. Is your stool black/ tarry?
    Never/NoSometimesAlways/Yes
    22. Have you lost weight without reason?
    Never/NoSometimesAlways/Yes
    23. Do you have painful bowel movements?
    Never/NoSometimesAlways/Yes
    24. Do you eliminate completely, or feel there is often something left?
    Never/NoSometimesAlways/Yes
    25. Do you have rectal pain before /after a motion?
    Never/NoSometimesAlways/Yes
    26. Do you have anal itching?
    Never/NoSometimesAlways/Yes
    27. Are you irritable and moody?
    Never/NoSometimesAlways/Yes
    28. Do you sleep well – at least 8 hours per night, undisturbed?
    Never/NoSometimesAlways/Yes
    29. Do you suffer from allergies / sinus problems?
    Never/NoSometimesAlways/Yes
    30. Do you get headaches?
    Never/NoSometimesAlways/Yes
    31. Do you have memory lapses/ problems concentrating?
    Never/NoSometimesAlways/Yes
    32. Do you suffer from athlete’s foot/tinea/nail fungus?
    Never/NoSometimesAlways/Yes
    33. Do you lack energy in the afternoon/ after eating a meal?
    Never/NoSometimesAlways/Yes
    34. Are you vegetarian?
    Never/NoSometimesAlways/Yes
    35. Do you eat meat, sausages, processed meats?
    Never/NoSometimesAlways/Yes
    36. Do you eat take a-ways/fried foods, sugars (including chocolate) more than 3 times a week?
    Never/NoSometimesAlways/Yes
    37. Do you drink at least 1 ½ L of purified water a day?
    Never/NoSometimesAlways/Yes
    38. Do you exercise at least 30 mins 3-4 times a week?
    Never/NoSometimesAlways/Yes
    39. Do you currently suffer with health problems?
    Never/NoSometimesAlways/Yes
    40. Are you unhappy with your current state of health?
    Never/NoSometimesAlways/Yes