Digestive Health Survey

The information you provide in this survey is confidential and is used only to better assist
you in reaching your optimal goals of natural health. Your survey information will be
submitted to Dr.'s Bryan and Belinda Massey to review with you upon your next appointment. If you
are not a local client but would like us to assist you further, natural health support and
guidance is available by phone. Under the Pricing menu option, click on "Support by Phone".

Name:

Email:

Phone number:

City & State:

Please check all the statements below that apply to you.

I feel fatigued more than energized.

I have one bowel movement or less everyday.

My stool is similar to toothpaste in consistency.

I experience an abundance of foul smelling gas.

My bowel movements are dense and heavy (fall to the
bottom of the toilet quickly).

I eat 30 to 40 grams of fiber everyday (1 apple=1 gram of fiber)

I am unable to lose weight even though I eat a healthy diet.

I take anti-depressants and / pain medications.

I drink 8 to 10 glasses of water every day.

I exercise at least 3 times per week.

Check the box if you can answer "Yes to any of the following questions:

Do you experience abdominal cramping and loose stools or constipation?

Do you have a sense of incomplete evacuation?

Do you pass mucus in your stool?

Do you often have abdominal bloating?

Does wheat (pasta, bread) cause abdominal cramping that is relieved by a bowel
movement?

Does dairy products cause you abdominal cramping that is relieved by a bowel
movement?

Do fatty foods such as meat, poultry skin, oils or nuts cause you abdominal cramping that
is relieved by a bowel movement?

Does soluble fiber like psyllium and vegetables like broccoli and cauliflower give you gas
and cramping?

Do you experience diarrhea or constipation after eating artificial sweeteners or sugar
alcohols? (mannitol, sorbitol, malitol)?

Have you ever experienced Candida or yeast overgrowth (nail fungus, athlete's foot,
thrush, vaginal yeast infections)?

Do you experience unexplained muscle aches and pains?

Do you experience normal bowel movements with bouts of intermittent diarrhea or
constipation?

Do you have unexplained weight loss and / or fever?

Do you have a distended belly?

Do you grind your teeth while sleeping?

Do you have dark circles under your eyes and / or acne?

Do you have insomnia or disturbed sleep?

Have you traveled outside of the United States?

Do you regularly eat unpeeled raw fruit and / or vegetables?

Do you have pets that sleep in bed with you or do you eat after contact with your pets?