Digestion Assessment Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Select all that apply for each question.

Email *

My hunger is:

Irregular, varies from meal to meal.

Generally strong; cannot skip meals.

Mild; can generally easily skip meals.

Clear selection

After eating, speed of digestion (time it takes to feel hungry again) is:

Irregular, varies from meal to meal.

Quick; I feel hungry again after only a couple of hours.

Slow; I'm not hungry again for 5-6 hours.

Clear selection

Food capacity (amount you can eat at a time):

Varies from meal to meal.

Large as compared to most other people.

Small as compared to most other people.

Clear selection

Fluctuations of body weight:

Easy to lose, difficult to gain; I tend to be underweight.

Can maintain normal weight even with fairly large food intake.

I gain weight easily, even with moderate food intake. Difficult to lose weight.

Clear selection

Energy level:

Variable or low compared to others.

Abundant compared to others.

Good, but may tend toward laziness.

Clear selection

Regularity of bowel movements:

Irregular, tending toward constipation.

Frequent; often more than 1-2 times a day.

Regular, once or twice daily

Clear selection

Quality of stool:

Hard, dry.

Loose.

Well-formed.

Clear selection

Select all symptoms that apply:

Gas/bloating

Frequent belching

Constipation

Intestinal cramping/discomfort

Acid reflux

Heartburn

Frequent diarrhea

Sluggish digestion

Heaviness or sleepy after eating

Sticky stools (or with mucus)

Send me a copy of my responses.

Submit

Clear form

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Forms