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