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BLUEPRINT Metabolic Health Questionnaire
In medicine today, leaky gut aka intestinal permeability, is not typically diagnosed. However, that does not mean it is not affecting your health. Many health issues related to LGS go undiagnosed, misdiagnosed, or are ignored by traditional medicine. Please take the questionnaire below to help our doctors evaluate how we can help your condition. 
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Email *
Phone Number *
First and Last name
Weight Trouble 
Constipation and/or Diarrhea
Abdominal Pain and/or Bloating
Mucous or Blood in  Stool
Joint Pain or Swelling, Arthritis
Chronic or Frequent Fatigue or Tiredness
Food Allergies, Sensitivities. or Intolerance
Sinus or Nasal Congestion
Chronic or Frequent Inflammations
Eczema, Skin Rashes or Hives (Urticaria)
Asthma, Hay Fever, or Airborne Allergies
Confusion, Poor Memory, or Mood Swings
Use of NSAIDS (Aspirin, Tylenol, Motrin)
History of Antibiotic use
Alcohol Consumption makes you feel sick
Ulcerative Colitis or Celiac's Disease
Nausea
Weight Trouble
Hormonal/Emotional Imbalance and/or PMS
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