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Confidential Health Questionniare

This questionnaire takes about 20 minutes to complete. 
All fields marked with an asterisk (*) are required.
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Animal Meat
Fish & Seafood
Vegetables
Fruit
Brown Fibre
White Fibre
Dairy Produce
Eggs
Legumes
Seeds
Nuts
Sweets & Sugar
Alcohol
Condiments
Non-Alcohol
Smoke
Drugs
Are your Stools:
Do you have:

Bristol Stool Chart

Bristol Stool Chart Type 1

Type 1

Separate hard lumps,

like nuts (hard to pass)

Bristol Stool Chart Type 4

Type 4

Like a Sausage or snake, smooth & soft

Bristol Stool Chart Type 2

Type 2

Sausage-shaped

(but lumpy)

Bristol Stool Chart Type 5

Type 5

Soft blobs, clear-cut edges, passed easily

Bristol Stool Chart Type 3

Type 3

Like a Sausage with cracks on its surface

Bristol Stool Chart Type 6

Type 6

Fluffy pieces, ragged edges, a mushy stool

Bristol Stool Chart Type 7

Type 7

Watery, no solid pieces entirely liquid

Do you have:
Do you have:
Have you felt the following symptoms consistently over the past month:
Do you:
Do you:
Do you have:
Do you have:
Do you have:
Muscleoskeletal Back
Muscleoskeletal Front
Do you have:
Do you have:
Experienced in last few months:
Have you had:
Do you have:
Do you have:
Have your family:
Have you:

Thank you - your Questionnaire has been Submitted

Main Presenting Symptoms

Supplements / Medication

Add Name of Product, Dose Amount, Time of Day, Reason for Taking, Date Started

Typical Daily Diet