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Dental Care & Wellness of Sonoma County


  Last name

  Mid Initial

  First name

Bowel Health Questionnaire

SECTION I : Digestive Enzymes
1. Bad breath, Halitosis 0 1 2 3
2. Loss of taste for high protein foods (Meat...) 0 1 2 3
3. Burning (acid) or Nervous stomach, Eating relieves 0 1 2 3
4. Gas shortly after eating 0 1 2 3
5. Indigestion ½ to 1 hour after eating may last 3-4 hours 0 1 2 3
6. Difficulty digesting fruits or vegetables; undigested foods found in stools 0 1 2 3
7. Acid or spicy foods upset stomach 0 1 2 3
8. Cannot tolerate Chlorella 0 1 2 3
SECTION II : Liver/Biliary Dys-Function
1. Lower bowel gas and or bloating several hours after eating 0 1 2 3
2. Feet burn 0 1 2 3
3. Whites of eyes (sclera) yellow 0 1 2 3
4. Dry skin, itchy feet and/or skin peels on feet 0 1 2 3
5. Brown spots or bronzing of skin 0 1 2 3
6. Bitter metallic taste in mouth 0 1 2 3
7. Blurred vision 0 1 2 3
8. Headache over eyes 0 1 2 3
9. Feel nauseous, queasy of gag easily 0 1 2 3
10. Color of stools light brown or yellow 0 1 2 3
11. Greasy or high fat foods cause distress 0 1 2 3
12. Pain between shoulder blades 0 1 2 3
13. Dark circles under eyes 0 1 2 3
14. Acid breath 0 1 2 3
15. History of gallbladder attacks or gallstones or gallbladder removed 0 1 2 3
16. Appetite reduced 0 1 2 3
SECTION III : Colon, Toxic Bowel
1. Coated tongue or fuzzy debris on tongue 0 1 2 3
2. Pass large amounts of foul smelling gas 0 1 2 3
3. Irritable bowel or mucous colitis 0 1 2 3
4. Constipation, Diarrhea, Alternating or Stool alternate from soft to watery 0 1 2 3
5. Bowel movements painful, or difficult, Constipation and/or laxatives used 0 1 2 3
6. Burning or itching anus 0 1 2 3
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