DIGESTIVE EVALUATION

(SOME OF THE FOLLOWING LIST IS FROM THE BOOK ADRENAL FATIQUE BY JAMES WILSON)

Rate the following from 0-5, with 0 being no problem & 5 being a severe problem.

Name *

First

Last

Gender *

Age *

Phone *

Email *

HISTORY

Have you had your zinc level checked in the last 6 months

How many glasses of water do you drink per day (please indicate #)

How many servings of fruits do you EAT each day (please indicate #)

Do you eat SUSHI?

Do you consume any dairy products

Have you taken antibiotics in the last 6 months or for an extended period of time during the last 10 years

Have you had any type of food allergy/ sensitivity testing performed?

Have you been diagnosed with any of the following?

Do you take OCT Antacids?

Do you take OCT Laxatives / Fiber

Ulcers-Gastric Duodenal

GERD/Reflux

Pancreatitis

IBS/IBD/Colitis

Other Digestive Aids Used (Please List):

Prescription Medicines for Digestion (Please List):

UPPER GI - BURNING, GERD, Indigestion

My stomach burns / hurts even when empty (No hunger pangs))

Eating or drinking relieves above

Eating or drinking make it worse

My stomach starts burning or I get bloated 30 min to sevral hours after I eat or drink

Certain foods seems to make this worse (please list)

What Relives this? (Please List)

I have been diagnosed with "Reflux" or "GERD"

If so, it is worse lying down OR lying down all the time

Lower GI - Gas, Bloating, Cramping, Constipation, Diarrhea

I have atleast 1 normal bowel movement each day.Normal is a large med brown well formed stool w/o cramping strain or pain

My stools are often:

Small and round or hard

Thin - Pencil like

Pasty or fatty

Loose

I often get really gassy and:

Its not nice but not really offensive

Very Offensive & Embaracing

Do any foods aggravate? Please list

I often have to strain to have a bowel movement

I often have cramping and pain with a Bowel movement

I often have abdominal cramping and pain even without a bowel movement.

I notice undigested food in my stool—especially vegetable matter.

Nutritional Exam points and history

Zinc

HCL point

Enzyme

Gallbladder

Liver

Please list the following as it applies:

Prescription medicines for digestion:

Foods that make GERD, heartburn worse:

What relieves heartburn or GERD:

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