SECTION D: ULCERS OR TOO MUCH STOMACH ACID IN THE WRONG PLACE
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2 17. Foul-smelling stool Gallstones/history of gallbladder disease Undigested food in stool Nausea Acid reflux/heartburn Connective tissue disease: lupus, rheumatoid arthritis, Sjogren's 23. Alcoholism, diabetes, osteoporosis... Score 0-6: Low priority Score 6-10: Moderate priority SECTION C: GASTRIC REFLUX 1. Sour taste in mouth Regurgitate undigested food into mouth Frequent nocturnal coughing Burning sensation from citrus on way to stomach... Score 0-3: Low priority Score 4-6: Moderate priority Score 7 or above: High priority 5. Heartburn Burping Difficulty swallowing solids or liquids... SECTION D: ULCERS OR TOO MUCH STOMACH ACID IN THE WRONG PLACE 1. Stomach pains Stomach pains before or after meals Dependency on antacids for heartburn/acid reflux.. 4. Chronic abdominal pain Butterfly sensations in stomach Burping or bloating Stomach pain when emotionally upset Sudden, acute indigestion Relief of symptoms by carbonated drinks Relief of stomach pain by drinking cream or milk History or family history of ulcer or gastritis Current ulcer Black stool when not taking iron supplements Use or previous use of pain medications: aspirin, ibuprofen, etc... Score 0-4: Low priority Score 5-8: Moderate priority Score 9 or above: High priority Page 4
3 SECTION E: LIVER AND GALLBLADDER 1. Intolerance to greasy foods Headaches after eating Light-colored stool Foul-smelling stool Less than one bowel movement daily Constipation Hard stool Sour taste in mouth Gray-colored skin Yellow in whites of eyes Bad breath Body odor Fatigue and sleepiness after eating Pain in right side under rib cage Pain when passing stool Water retention Painful big toe Pain radiates along outside of leg Dry skin or hair Red blood in stool... (No = 0 More than two years ago = 1 Current = 2 Chronic = 3) 21. Have had jaundice or hepatitis... (No = 0 More than two years ago = 1 Current = 2 Chronic = 3) 22. High blood cholesterol and low HDL cholesterol (No = 0 Unknown (blank) Yes = 2) 23 Cholesterol level above (No = 0 Unknown (blank) Yes = 2) 24. Triglyceride level above (No = 0 Unknown (blank) Yes = 2-3) Score 0-2: Low priority Score 3-5: Moderate priority Score 6 or above: High priority SECTION F: SMALL INTESTINAL BACTERIAL OVERGROWTH 1. Excessive gas/flatulence Abdominal bloating and distension, especially with sugar, fiber or carbohydrates Diarrhea Abdominal pain Irritable bowel syndrome Fibromyalgia Restless leg syndrome Intolerance to probiotic supplements Scored 9 or more on Section A Are taking antacids or proton pump inhibitors for heartburn/gerd... Score 0-4: Low priority Score 5-9: Moderate priority Page 5
4 SECTION G: INTESTINAL PERMEABILITY/LEAKY GUT SYNDROME DYSBIOSIS 1. Constipation and/or diarrhea Abdominal pain or bloating Mucus or blood in stool Joint pain or swelling, or arthritis Chronic or frequent fatigue or tiredness Food allergy or food sensitivities or intolerance Sinus or nasal congestion Chronic or frequent inflammations Asthma, hay fever or airborne allergies... SECTION H: GLUTEN SENSITIVITY Digestive 1. Bloating and/or gas Constipation and/or diarrhea Nausea Weight trouble Iron-deficiency anemia... Hormonal 6. Fatigue Sleep problems Depression, anxiety and/or mood swings Menstrual problems Infertility Confusion, poor memory or mood swings Use of nonsteroidal anti-inflammatory drugs (aspirin, Tylenol, Motrin) History of antibiotic use Alcohol consumption or alcohol makes you feel sick Ulcerative colitis, Crohn's disease or celiac disease Headaches or migraine headaches Chronic nasal congestion... Score 1-5: Low priority Score 6-10: Mild priority Score 7-19 Moderate priority Score 20 or above: High priority Neurological 13. Headaches and/or migraines Memory problems Joint pains or aches Fibromyalgia Brain fog... Immune System 18. Get infections easily History or family history of arthritis, any type History or family history of cancer History or family history of autoimmune disease HIstory or family history of celiac disease Thyroid problems Osteoporosis or osteopenia... Score 0-6: Low priority Score 6-10: Moderate priority Page 6
5 The section on gluten intolerance was adapted with permission from: Drs. Vikki andrichard Petersen, DC, CCN, The Gluten Effect, True Health Publishing, 2009; Sunnyvale, CA. SECTION I: COLON/LARGE INTESTINE 1. Seasonal or recurring diarrhea Frequent and recurrent infections (colds) Bladder and kidney infections Vaginal yeast infection Abdominal cramps Toe and fingernail fungus Alternating diarrhea and constipation Constipation Meat eater... (Never = 0 Rarely = 1 Often = 2 Daily = 3) 11. Rapidly failing vision Recurrent stomach pain Blood or pus in stool Family history of inflammatory bowel disease... Score 0-5: Low priority Score 6-9: Moderate priority 9. History of antibiotic use... Page 7
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