Self-Assessment Questionnaire

Personal Health Design (PhD) Screening Tool

Our PhD is a health 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.

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

Instructions:
Select the number which best describes the intensity of your symptoms. If you do not know the answer to a question, select “0”. Our experts will review your submission and you will receive recommendations based on your assessment within 48 hours.

Complete This Form & Generate Your Results

"*" indicates required fields

Gastric Reflux

1. Sour taste in mouth
2. Regurgitate undigested food into mouth
3. Frequent nocturnal coughing
4. Burning sensation from citrus on way to stomach
5. Struggles with muscle tone
6. Heartburn
7. Burping
8. Difficulty swallowing solids or liquids

Intestinal Permeability/Leaky gut Syndrome

1. Weight loss plateau
2. Constipation and/or diarrhea
3. Abdominal pain or bloating
4. Burning sensation from citrus on way to stomach
5. Join pain or swelling, or arthritis
6. Chronic or frequent fatigue or tiredness
7. Food allergy or food sensitivities or intolerance
8. Sinus or nasal congestion
9. Chronic or frequent inflammations
10. Eczema, skin rashes, or hives
11. Dry, flaky skin &/or dry brittle hair
12. Asthma, hayfever, or airborne allergies
13. Confusion, poor memory, or mood swings
14. Use of nonsteroidal anti-inflammatory drugs (aspirin, Tylenol, Motrin)
15. History of antibiotic use
16. Alcohol consumption, or alcohol makes you feel sick
17. Autoimmune conditions
(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
2. My mood fluctuates greatly during the day
3. My mood changes with my menstrual cycle
4. I feel nervous or worried
5. I experience anxiety, panic attacks or anxious moments
6. I often feel irritable or grumpy
7. I feel overwhelmed
8. I often feel emotionally sensitive or weepy
9. I wake up in the middle of the night, even just to go to the bathroom
10. I don't feel refreshed after a night's sleep
11. It takes me more than 15 minutes to fall asleep

Colon/Large Intestine/Microbiome

1. Seasonal diarrhea
2. Frequent and recurrent infections (colds)
3. Bladder and kidney infection
4. Vaginal yeast infection
5. Abdominal cramps
6. Toe and fingernail fungus
7. Alternating diarrhea/constipation
8. Constipation
9. History of antibiotic use
10. Weight concerns
11. Crave sugar and carbs
12. Meat eater
13. Conventional dairy
This field is for validation purposes and should be left unchanged.