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Digestive System Assessment

Personal Health Design (PhD) Questionnaire

Our PhD is a questionnaire that will help you assess your digestive status. It is not meant as a replacement for a physician’s care. This questionnaire will help you discover where your digestive system may be having problems. It is a screening tool only and does not constitute a diagnosis of your problem. However, it can point you in the right direction in determining where the highest priorities lie in your healing process.

Instructions:
Select the number which best describes the intensity of your symptoms. If you do not know the answer to a question, select “0”. Once you click SUBMIT you will see recommendations based on your score.

0 = Symptom is not present/rarely present
1 = Mild/sometimes
2 = Moderate/often
3 = Severe/almost always

Name*
Phone*
Email*
Gastric Reflux
1. Sour taste in mouth
- 0
- 1
- 2
- 3
2. Regurgitate undigested food into mouth
- 0
- 1
- 2
- 3
3. Frequent nocturnal coughing
- 0
- 1
- 2
- 3
4. Burning sensation from citrus on way to stomach
- 0
- 1
- 2
- 3
5. Struggles with muscle tone
- 0
- 1
- 2
- 3
6. Heartburn
- 0
- 1
- 2
- 3
7. Burping
- 0
- 1
- 2
- 3
8. Difficulty swallowing solids or liquids
- 0
- 1
- 2
- 3
Intestinal Permeability/Leaky gut Syndrome
1. Weight loss plateau
- 0
- 1
- 2
- 3
2. Constipation and/or diarrhea
- 0
- 1
- 2
- 3
3. Abdominal pain or bloating
- 0
- 1
- 2
- 3
4. Burning sensation from citrus on way to stomach
- 0
- 1
- 2
- 3
5. Join pain or swelling, or arthritis
- 0
- 1
- 2
- 3
6. Chronic or frequent fatigue or tiredness
- 0
- 1
- 2
- 3
7. Food allergy or food sensitivities or intolerance
- 0
- 1
- 2
- 3
8. Sinus or nasal congestion
- 0
- 1
- 2
- 3
9. Chronic or frequent inflammations
- 0
- 1
- 2
- 3
10. Eczema, skin rashes, or hives
- 0
- 1
- 2
- 3
11. Dry, flaky skin &/or dry brittle hair
- 0
- 1
- 2
- 3
12. Asthma, hayfever, or airborne allergies
- 0
- 1
- 2
- 3
13. Confusion, poor memory, or mood swings
- 0
- 1
- 2
- 3
14. Use of nonsteroidal anti-inflammatory drugs (aspirin, Tylenol, Motrin)
- 0
- 1
- 2
- 3
15. History of antibiotic use
- 0
- 1
- 2
- 3
16. Alcohol consumption, or alcohol makes you feel sick
- 0
- 1
- 2
- 3
17. Autoimmune conditions
- 0
- 1
- 2
- 3
(ex: Hashimoto's thyroiditis, rheumatoid arthritis, lupus, Celiac disease, scleroderma, Addison's disease, Graves' disease, Type 1 diabetes, vitiligo, Psoriasis, etc.)
Mood/Sleep
1. I feel that I'm in a low or depressed mood
- 0
- 1
- 2
- 3
2. My mood fluctuates greatly during the day
- 0
- 1
- 2
- 3
3. My mood changes with my menstrual cycle
- 0
- 1
- 2
- 3
4. I feel nervous or worried
- 0
- 1
- 2
- 3
5. I experience anxiety, panic attacks or anxious moments
- 0
- 1
- 2
- 3
6. I often feel irritable or grumpy
- 0
- 1
- 2
- 3
7. I feel overwhelmed
- 0
- 1
- 2
- 3
8. I often feel emotionally sensitive or weepy
- 0
- 1
- 2
- 3
9. I wake up in the middle of the night, even just to go to the bathroom
- 0
- 1
- 2
- 3
10. I don't feel refreshed after a night's sleep
- 0
- 1
- 2
- 3
11. It takes me more than 15 minutes to fall asleep
- 0
- 1
- 2
- 3
Colon/Large Intestine/Microbiome
1. Seasonal diarrhea
- 0
- 1
- 2
- 3
2. Frequent and recurrent infections (colds)
- 0
- 1
- 2
- 3
3. Bladder and kidney infection
- 0
- 1
- 2
- 3
4. Vaginal yeast infection
- 0
- 1
- 2
- 3
5. Abdominal cramps
- 0
- 1
- 2
- 3
6. Toe and fingernail fungus
- 0
- 1
- 2
- 3
7. Alternating diarrhea/constipation
- 0
- 1
- 2
- 3
8. Constipation
- 0
- 1
- 2
- 3
9. History of antibiotic use
- 0
- 1
- 2
- 3
10. Weight concerns
- 0
- 1
- 2
- 3
11. Crave sugar and carbs
- 0
- 1
- 2
- 3
12. Meat eater
- 0
- 1
- 2
- 3
13. Conventional dairy
- 0
- 1
- 2
- 3
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Name
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