Symptom Questionnaire
Instructions
Warning! If you are shy about your symptoms, this may be a waste of your time. If you share details, yes even about bowel health, continue on!
For example, bowel health is something we take for granted until we lose it. We often LIVE with poor bowel health.
So if you are ready to be honest, then I can have a greater probability of helping you.
The Majority of my patients come with some inflammation in one or more parts of their body that come out as a symptom somewhere else on their body. The truth is, the symptom location may be the end not the beginning of that symptom. Bowel symptoms and other symptom questions below will help me find the cause. This is a secure website using 128 bit encryption so don't worry about privacy. If you are concerned, and want to us to email or fax the questionnaire to you just call us at 714.528.2219.
For example, the first set of questions below involve digestion because it is foundational to your health and symptom(s).
Rate each of the following symptoms based upon your typical health profile. Select the number that best corresponds to the frequency and severity of the symptoms as noted below:
0 = Never or almost never have the symptoms
1 = Occasionally have it; effect is not severe
2 = Occasionally have it; effect is severe
3 = Frequently have it; effect is not severe
4 = Frequently have it; effect is severe
Afterwards, add up the numbers to arrive at a total for each section and add it in the proper box. Then, add the totals for each section to arrive at the grand total, which we will ask for at the end of the questionnaire.
