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724 S. Beach, Suite 1. Daytona Beach, FL 32114
bridget@www.bwellbhealthy.com
386-871-6477
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386-871-6477
How Healthy Is Your Gut
Book a Free 15-Minute Consultation
How Healthy Is YOUR Gut? Fill Out this Gut Health Questionnaire & get a FREE 15-min Consultation with Bridget
Please answer all questions to the best of your ability.
Email
Phone Number
Full Name
Do you suffer from Gastrointestinal discomfort: gas, bloating, abdominal pain, etc?
Never
Sometimes
Daily
Do you struggle with diarrhea?
Never
Sometimes
Daily
Do you struggle with constipation?
Never
Sometimes
Daily
Are you able to easily digest beans and fiber without any issues?
Never
Sometimes
Daily
Do you experience uncomfortable fullness in the stomach?
Never
Sometimes
Daily
Do you experience cramps, urgency or mucus and blood in your stool?
Never
Sometimes
Daily
Do you struggle with itching in the vagina, anus, or in other mucosal membranes?
Never
Sometimes
Daily
Describe your energy level most days.
Tired, fatigued and require more sleep than desired to get through the day
Slow to start in the morning and rely on caffeine to get through the day and have difficult sleeping
Consistently have enough energy to get through the day and sleep easily and effortlessly
Do you ever suffer from bad breath?
Never
Sometimes
Daily
Do you crave sugar and carbohydrates?
Never
Sometimes
Daily
Do you suffer with any skin issues: rashes, eczema, acne, etc? Please list and explain.
Do you have difficulty gaining and maintaining a healthy weight?
Yes
No
Sometimes
Do you have difficulty losing and maintaining a healthy weight?
Yes
No
Sometimes
Do you suffer with sinus congestion?
Never
Sometimes
Daily
Have you used antacids daily for more than 30 days in the past two years?
Yes
No
Have you taken antibiotics more than 3 times in the past year?
Yes
No
Do you have a history of traveller's diarrhea or foreign travel?
Yes
No
Do you have any food sensitivities?
Yes
No
Do you have any environmental sensitivities?
Yes
No
Have you been diagnosed with an autoimmune disease or condition?
Yes
No
Have you been diagnosed with arthritis or fibromyalgia?
Yes
No
Submit
724 S. Beach, Suite 1. Daytona Beach, FL 32114
bridget@www.bwellbhealthy.com
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