Digestive health Questionnaire

The Digestive Health Appraisal Questionnaire — is a clinically-informed tool designed to help identify areas of digestive function that may be compromised, under stress, or in need of further investigation.

Each section reflects a different stage of the digestive process — from oral health to colon function — and your scores offer insight into how well these systems are functioning. Based on your answers, we’ll guide you through:

  • Systems scoring low (likely functioning well)

  • Systems scoring moderate (may need monitoring or mild support)

  • Systems scoring high (may benefit from root-cause investigation, testing, or therapy)

🔎 What Your Scores Mean

Each section is scored using a 0–3 scale:

  • 0 = Symptom not present or very rare

  • 1 = Mild / sometimes present

  • 2 = Moderate / often present

  • 3 = Severe / almost always present

The totals are categorized to reflect relative clinical risk — not just the number of symptoms. This reduces the chance of misinterpretation or exaggeration and instead highlights systems where your symptom pattern reflects genuine dysfunction.

Digestive Health Questionnaire (#38)

Understanding Digestive Health: Why It Matters & How We Assess It

 

Your digestive system is like a complex highway that processes everything you eat, absorbing nutrients, removing waste, and protecting your body from harmful substances. This journey starts in the mouth, where digestion begins with chewing and saliva, and continues through the stomach, small intestine, and large intestine (colon) before finally eliminating waste. Each step of this process needs to function properly for optimal digestion, nutrient absorption, and overall health.

When something goes wrong along this digestive highway, symptoms can arise—bloating, gas, acid reflux, diarrhea, constipation, fatigue, skin issues, or even brain fog. These symptoms may seem unrelated, but they often stem from underlying imbalances like low stomach acid, enzyme deficiencies, bacterial overgrowth (SIBO), gut inflammation, or dysbiosis (an imbalance of good and bad bacteria). If left unaddressed, poor digestion can lead to nutrient deficiencies, autoimmune diseases, chronic inflammation, and even metabolic issues.

 

Why Do We Use a Questionnaire for Root Cause Assessment?

 

Because digestive symptoms are highly interconnected, we use a comprehensive questionnaire to map out patterns and identify potential root causes. The questionnaire helps us determine:

- Which part of the digestive tract is dysfunctional?

     -  Is it low stomach acid? Enzyme deficiency? SIBO? Leaky gut?

- Is the issue causing systemic problems?

     -  Are symptoms affecting energy levels, mood, skin, joints, or immunity?

- Does this require further medical testing?

     -  The responses help determine if lab testing is necessary to confirm imbalances.

 

Which Tests Are Recommended Based on Symptoms?

After analyzing the questionnaire responses, specific tests can help pinpoint the exact cause of digestive dysfunction and guide the healing process.

Choose the number which best describes the intensity of your symptoms. If you do not know the answer to a question, leave it blank. The form totals each section automatically. Once complete, view the totals for each section to assess which areas need your attention.

KEY:     

Leave blank (0) =

  • 0 = Symptom is not present/rarely present
  • 1 = Mild/sometimes
  • 2 = Moderate/often
  • 3 = Severe/almost always

Section A - Oral and Dental Health

0123
1. A sore in your mouth that doesn’t heal
2. Bleeding or swelling after brushing/flossing
3. Canker sores or cold sores
4. Chronic bad breath or sour taste
6. Dry mouth / poor salivation
7. Fissures in the tongue or geographic tongue
0123
8. Loose teeth or receding gums
9. Periodontal disease
10. Sensitivity to hot or cold foods
11. Sores in the mouth
12. Swelling of the jaw
13. White patches on tongue or cheeks

Scoring:

  • 0-5 = Low priority
  • 6-9= Moderate priority
  • 10+ = High priority

Section B - Eosinophilic Esophagitis and Esophagitis

  • 0 = Symptom is not present/rarely present - Leave Blank
  • 1 = Mild/sometimes
  • 2 = Moderate/often
  • 3 = Severe/almost always
0123
1. Problems with swallowing or painful swallowing (dysphagia)
2. Food gets stuck/impacted in esophagus after swallowing
3. Need to regurgitate or vomit food and/or nausea
0123
4. GERD medications, such as proton pump inhibitors, don’t help the problem
5. Chest or abdominal pain with eating
6. Heartburn or GERD

Scoring:

  • 0-3 = Low priority
  • 4-6= Moderate priority
  • 7+ = High priority

Section C - Hypoacidity of the Stomach

  • 0 = Symptom is not present/rarely present - Leave Blank
  • 1 = Mild/sometimes
  • 2 = Moderate/often
  • 3 = Severe/almost always
0123
1. Burping or bloated after eating
2. Feels like food sits in stomach
3. History of allergies or autoimmune disease
4. Easily gets food poisoning
5. Stomach upsets easily
6. History of constipation
7. Known food allergies
0123
8. Iron deficiency anemia
9. Nausea after taking supplements
10. Undigested food in stool
11. History of small intestinal bacterial overgrowth
12. Age 75-79 = 1 point, age 80-84 = 2 points, age ≥85 = 3 points
13. Takes antacids or Proton Pump Inhibitors (PPIs)
14. Pruritis ani (itchy anus)

Scoring:

  • 0-7 = Low priority
  • 8-12 = Moderate priority
  • 13+ = High priority

Section D - Gastric Reflux

  • 0 = Symptom is not present/rarely present - Leave Blank
  • 1 = Mild/sometimes
  • 2 = Moderate/often
  • 3 = Severe/almost always
0123
1. Sour taste in mouth
2. Regurgitate undigested food into mouth
3. Frequent coughing
4. Burning sensation from citrus in throat
0123
5. Heartburn
6. Burping
7. Difficulty swallowing solids or liquids

Scoring:

  • 0-3 = Low priority
  • 4-6 = Moderate priority
  • 7+ = High priority

Section E - Hypofunction of Small Intestines & Pancreas

  • 0 = Symptom is not present/rarely present - Leave Blank
  • 1 = Mild/sometimes
  • 2 = Moderate/often
  • 3 = Severe/almost always
0123
1. Abdominal cramps
2. Indigestion 1-3 hours after eating
3. Fatigue after eating
4. Lower bowel gas
5. Alternating constipation & diarrhea
6. Diarrhea
7. Roughage & fiber causes constipation
8. Mucus in stools
9. Stool poorly formed
10. Shiny stool
11. Three or more large bowel movements daily
12. Dry, flaky skin &/or dry brittle hair
0123
13. Pain in left side under rib cage or chronic stomach pain
14. Adult acne
15. Food allergies
16. Difficulty gaining weight
17. Foul-smelling stool
18. Gallstones/history of gallbladder disease
19. Undigested food in stool
20. Nausea
21. Acid reflux/heartburn
22. Connective tissue disease: lupus, RA, Sjogren’s
23. Alcoholism, diabetes, osteoporosis

Scoring:

  • 0-6 = Low priority
  • 7-12 = Moderate priority
  • 13+ = High priority

Section F - Ulcers

  • 0 = Symptom is not present/rarely present - Leave Blank
  • 1 = Mild/sometimes
  • 2 = Moderate/often
  • 3 = Severe/almost always
0123
1. Stomach pains
2. Stomach pains before or after me
3. Dependency on antacids or PPIs for heartburn/GERD
4. Chronic abdominal pain
5. "Butterflies" sensation in stomach
6. Burping or bloating
7. Stomach pain when emotionally upset
0123
8. Sudden, acute indigestion
9. Relief of symptoms by carbonated drinks
10. Relief of stomach pain by drinking cream/milk
11. History or family history of ulcer or gastritis
12. Current ulcer
13. Black stool (not due to iron supplements)
14. Use or past use of pain medications (aspirin, ibuprofen, etc.)

Scoring:

  • 0-4 = Low priority
  • 5-8 = Moderate priority
  • 9+ = High priority

Section G - Enzyme Insufficiencies

  • 0 = Symptom is not present/rarely present - Leave Blank
  • 1 = Mild/sometimes
  • 2 = Moderate/often
  • 3 = Severe/almost always
0123
1. Lactose, fructose, or sucrose intolerance
2. Undigested food in stool
3. Abdominal discomfort, bloating, gas
4. Bleeding tendency (vitamin K deficiency)
5. Difficulty gaining weight
6. Fatigue with no clear reason
0123
7. Food sensitivities
8. Transient low blood sugar
9. Malabsorption issues
10. Pale or tan stools, possibly frothy and bad-smelling
11. Stools that float

Scoring:

  • 0-4 = Low priority
  • 5-8 = Moderate priority
  • 9+ = High priority

Section H - Liver & Gallbladder

  • 0 = Symptom is not present/rarely present - Leave Blank
  • 1 = Mild/sometimes
  • 2 = Moderate/often
  • 3 = Severe/almost always
0123
1. Trouble digesting foods with fats and oils
2. Jaundice or yellowing of whites of the eyes
3. Nausea and vomiting
4. Feeling queasy after a fatty meal
5. Feeling of fullness or pain in belly, shoulders, or head
6. History of gallbladder removal or gallstones
7. Light or tan-colored, frothy stools that smell bad
8. Diarrhea
9. Gas and bloating
10. Low serum albumin levels
11. Bleeding tendency (vitamin K deficiency)
12. Less than one bowel movement daily
0123
13. Itchy skin
14. Lack of appetite
15. Dark-colored urine
16. Bitter or sour taste in mouth after eating
17. Water retention in legs and ankles
18. Painful big toe
19. Pain radiating along outside of leg
20. Dry skin/hair
21. Red blood in stool
22. History of jaundice or hepatitis
23. High blood cholesterol and/or triglycerides

Scoring:

  • 0-7 = Low priority
  • 8-14 = Moderate priority
  • 15+ = High priority

Section I - Food Sensitivities

  • 0 = Symptom is not present/rarely present - Leave Blank
  • 1 = Mild/sometimes
  • 2 = Moderate/often
  • 3 = Severe/almost always
0123
1. Nausea
2. Diarrhea
3. Abdominal pain or discomfort
4. Neurological issues (brain fog, depression, difficulty focusing)
0123
5. Rashes or hives
6. Unexplained fatigue, joint pain, or muscle pain
7. Diagnosed with an autoimmune disorder
8. Digestive issues

Scoring:

  • 0-4 = Low priority
  • 5-8 = Moderate priority
  • 9+ = High priority

Section J - Food Allergies

  • 0 = Symptom is not present/rarely present - Leave Blank
  • 1 = Mild/sometimes
  • 2 = Moderate/often
  • 3 = Severe/almost always
0123
1. Itching, rash, hives, or flushing
2. Itching or tingling in the mouth or on tongue
3. Swollen lips, face, tongue, throat, etc.
4. Symptoms come on rapidly after eating
5. Chronic sinusitis
0123
6. Nausea and/or abdominal cramping
7. Diagnosed with allergies (hay fever, asthma, eczema)
8. Diarrhea
9. Dizziness, fainting, or lightheadedness

Scoring:

  • 0-4 = Low priority
  • 5-8 = Moderate priority
  • 9+ = High priority

Section K - Intestinal Permeability (Leaky Gut) / Dysbiosis

  • 0 = Symptom is not present/rarely present - Leave Blank
  • 1 = Mild/sometimes
  • 2 = Moderate/often
  • 3 = Severe/almost always
0123
1. Constipation and/or diarrhea
2. Abdominal pain or bloating
3. Mucus or blood in stool
4. Joint pain or swelling, or arthritis
5. Chronic or frequent fatigue or tiredness
6. Food allergy or food sensitivities or intolerances
7. Sinus or nasal congestion
8. Chronic or frequent inflammations
9. Eczema, skin rashes, or hives (urticaria)
0123
10. Asthma, hay fever, or airborne allergies
11. Confusion, poor memory, or mood swings
12. Use of non-steroidal anti-inflammatory drugs (aspirin, ibuprofen)
13. History of antibiotic use
14. Alcohol consumption, or alcohol makes you feel sick
15. Ulcerative colitis, Crohn’s disease, or celiac disease
16. Headaches or migraine headaches
17. Chronic nasal congestion

Scoring:

  • 1-6 = Low priority
  • 7-19 = Moderate priority
  • 20+ = High priority

Section L - Small Intestinal Bacterial Overgrowth

  • 0 = Symptom is not present/rarely present - Leave Blank
  • 1 = Mild/sometimes
  • 2 = Moderate/often
  • 3 = Severe/almost always
0123
1. Stomach pains
2. Stomach pains before or after meals
3. Abdominal bloating and distension, especially with sugar, fiber, or carbohydrates
4. Abdominal pain, cramping, mucus, or blood in stools
5. Irritable bowel syndrome
6. Fibromyalgia
7. Restless leg syndrome
8. Interstitial cystitis
0123
9. Chronic constipation
10. Intolerance to probiotic supplements
11. Scored 9 or more on section A
12. Currently taking antacids or proton pump inhibitors
13. Fatigue/Low energy
14. Depression or anxiety
15. Bad breath

Scoring:

  • 0-4 = Low priority
  • 5-9 = Moderate priority
  • 10+ = High priority

Section M - Dysbiosis: Fungal Overgrowth

  • 0 = Symptom is not present/rarely present - Leave Blank
  • 1 = Mild/sometimes
  • 2 = Moderate/often
  • 3 = Severe/almost always
0123
1. Recurring vaginal, nail, skin, or other fungal infections
2. Diarrhea, constipation, or both
3. Unexplained fatigue and/or brain fog
4. Depression and/or anxiety
5. Chronic sinusitis
0123
6. Itching in vagina, anus, ears, or other mucous membranes
7. Gas and/or bloating
8. Diagnosis of autoimmune disease
9. Skin issues: eczema, psoriasis, hives, rashes
10. Low blood sugar issues, mood swings

Scoring:

  • 0-4 = Low priority
  • 5-9 = Moderate priority
  • 10+ = High priority

Section N - Celiac Disease, Gluten Sensitivity, Wheat Reactions

  • 0 = Symptom is not present/rarely present - Leave Blank
  • 1 = Mild/sometimes
  • 2 = Moderate/often
  • 3 = Severe/almost always
0123
1. Bloating and/or gas
2. Constipation and/or diarrhea
3. Nausea
4. Weight trouble
5. Iron-deficiency anemia
0123
6. Fatigue
7. Sleep problems
8. Depression, anxiety, and/or mood swings
9. Menstrual problems
10. Infertility
11. Thyroid problems
12. Osteoporosis or osteopenia
0123
13. Headaches and/or migraines
14. Memory problems
15. Joint pains or aches
16. Fibromyalgia
17. Brain fog
0123
18. Get infections easily
19. Arthritis, any type, you or family
20. Cancer history, you or family
21. Autoimmune disease, you or family
22. Celiac disease, you or family

Scoring:

  • 0-5 = Low priority
  • 6-10 = Moderate priority
  • 11+ = High priority

  • 0 = Symptom is not present/rarely present - Leave Blank
  • 1 = Mild/sometimes
  • 2 = Moderate/often
  • 3 = Severe/almost always
0123
1. Seasonal or recurring diarrhea
2. Frequent and recurrent infections (colds)
3. Bladder and kidney infections
4. Vaginal yeast infection
5. Abdominal cramps
6. Toe and fingernail fungus
7. Alternating diarrhea/constipation
0123
8. Constipation
9. History of antibiotic use
10. Meat eater
11. Rapidly failing vision
12. Recurrent stomach pain
13. Blood or pus in stool
14. Family history of IBD (Inflammatory Bowel Disease)

Scoring:

  • 0-5 = Low priority
  • 6-9 = Moderate priority
  • 10+ = High priority

Digestive Health Questionnaire Disclaimer:

By completing this questionnaire, I acknowledge the following:

1. Accuracy of Information: I confirm that all information provided is accurate and true to the best of my knowledge.
2. Purpose of Questionnaire: I understand that this questionnaire is for assessment purposes only and does not establish a practitioner-client relationship or any commitment to work together.
3. Non-Substitute for Medical Advice: I recognize that any insights or recommendations provided are for informational purposes and are not a replacement for medical advice from a qualified healthcare provider.
4. Personalized Guidance: I understand that any guidance received is tailored to my individual circumstances and may not apply to others.