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GUT & MICROBIOME QUESTIONNAIRE

Results will be sent to your email

INSTRUCTIONS:

For each statement, select how often it applies to you.

0 = Never

1 = Occasionally

2 = Often

3 = Almost Always

DIGESTION & ELIMINATION

1. Bloating after eating

0=Never, 1=Occasionally, 2=Often, 3=Almost Always

2. Gas or burping frequently

0=Never, 1=Occasionally, 2=Often, 3=Almost Always

3. Feeling full quickly

0=Never, 1=Occasionally, 2=Often, 3=Almost Always

4. Constipation or infrequent bowel movements

0=Never, 1=Occasionally, 2=Often, 3=Almost Always

5. Loose stools or urgency

0=Never, 1=Occasionally, 2=Often, 3=Almost Always

6. Alternating constipation and diarrhea

0=Never, 1=Occasionally, 2=Often, 3=Almost Always

7. Undigested food visible in stools

0=Never, 1=Occasionally, 2=Often, 3=Almost Always

8. Heartburn or reflux

0=Never, 1=Occasionally, 2=Often, 3=Almost Always

9. Straining or incomplete evacuation

0=Never, 1=Occasionally, 2=Often, 3=Almost Always

INFLAMMATION & IMMUNE SIGNALS

10. Frequent infections (sinus, respiratory, urinary, etc.)

0=Never, 1=Occasionally, 2=Often, 3=Almost Always

11. Seasonal allergies or food sensitivities

0=Never, 1=Occasionally, 2=Often, 3=Almost Always

12. Joint soreness or systemic aches

0=Never, 1=Occasionally, 2=Often, 3=Almost Always

13. Skin issues (eczema, psoriasis, acne, rashes)

0=Never, 1=Occasionally, 2=Often, 3=Almost Always

14. Chronic fatigue or afternoon crashes

0=Never, 1=Occasionally, 2=Often, 3=Almost Always

HORMONE & METABOLIC CLUES

15. Poor sleep or restless nights

0=Never, 1=Occasionally, 2=Often, 3=Almost Always

16. Mood swings or emotional irritability

0=Never, 1=Occasionally, 2=Often, 3=Almost Always

17. Weight resistance despite lifestyle changes

0=Never, 1=Occasionally, 2=Often, 3=Almost Always

18. Sugar cravings, especially late-day/evening

0=Never, 1=Occasionally, 2=Often, 3=Almost Always

19. Brain fog or difficulty focusing

0=Never, 1=Occasionally, 2=Often, 3=Almost Always

GUT--BRAIN CONNECTION

20. Anxiety or stress worsens digestive symptoms

0=Never, 1=Occasionally, 2=Often, 3=Almost Always

21. History or trauma, chronic stress, or burnout

0=Never, 1=Occasionally, 2=Often, 3=Almost Always

22. Feeling "wired but tired"

0=Never, 1=Occasionally, 2=Often, 3=Almost Always

23. Low resilience to stress or overwhelm

0=Never, 1=Occasionally, 2=Often, 3=Almost Always

24. Feeling inflamed or "puffy"

0=Never, 1=Occasionally, 2=Often, 3=Almost Always

HISTORY / RISK FACTORS

25. Past antibiotics or long-term medication use

0=Never, 1=Occasionally, 2=Often, 3=Almost Always

26. Highly processed food intake

0=Never, 1=Occasionally, 2=Often, 3=Almost Always

27. Low fiber or inconsistent vegetable intake

0=Never, 1=Occasionally, 2=Often, 3=Almost Always

28. Frequent alcohol or caffeine use

0=Never, 1=Occasionally, 2=Often, 3=Almost Always

29. Sedentary periods or limited movement

0=Never, 1=Occasionally, 2=Often, 3=Almost Always

Consent & Acknowledgement

By submitting this form, I acknowledge that the information provided is truthful to the best of my knowledge. I understand that this questionnaire is for wellness and educational purposes only and does not establish a medical provider–patient relationship. I further understand that the results will be reviewed by Dr. Sandra McKenzie for the purpose of offering general wellness guidance or discussing next steps, and that any personalized recommendations will require a formal consultation.

This questionnaire is a screening tool, not a diagnosis.

Results help guide awareness and discussion.

Personalized recommendations require a clinical consultation.

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