Leaky Gut Syndrome Questionaire

					

				
				

				
							

								

						

				
Welcome to your Leaky Gut Syndrome Questionnaire
This questionnaire has been reprinted from Dr. Elizabeth's Lipski's book, Leaky Gut Syndrome.
Circle the number that mostly fits.

1 = Symptom is not present or rarely present

2 = Mild/sometimes

3 = Moderate/often

4 = Severe/almost always
						
								

												Please provide your email to have your results emailed to you:
							
											
									
									

					

	Constipation and/or diarrhea	
		

							
						
							1						
											
										
						
							2						
											
										
						
							3						
											
										
						
							4						
											
								
			 	
						
									

					

	Abdominal pain or bloating	
		

							
						
							1						
											
										
						
							2						
											
										
						
							3						
											
										
						
							4						
											
								
			 	
						
									

					

	Joint pain, swelling, arthritis	
		

							
						
							1						
											
										
						
							2						
											
										
						
							3						
											
										
						
							4						
											
								
			 	
						
									

					

	Chronic or frequent fatigue or tiredness	
		

							
						
							1						
											
										
						
							2						
											
										
						
							3						
											
										
						
							4						
											
								
			 	
						
									

					

	Food allergies, sensitivities or intolerance	
		

							
						
							1						
											
										
						
							2						
											
										
						
							3						
											
										
						
							4						
											
								
			 	
						
									

					

	Sinus or nasal congestion	
		

							
						
							1						
											
										
						
							2						
											
										
						
							3						
											
										
						
							4						
											
								
			 	
						
									

					

	Chronic or frequent inflamations	
		

							
						
							1						
											
										
						
							2						
											
										
						
							3						
											
										
						
							4						
											
								
			 	
						
									

					

	Eczema, skin rashes or hives, asthma, hay fever, or air borne allergies	
		

							
						
							1						
											
										
						
							2						
											
										
						
							3						
											
										
						
							4						
											
								
			 	
						
									

					

	Confusion, poor memory or mood swings	
		

							
						
							1						
											
										
						
							2						
											
										
						
							3						
											
										
						
							4						
											
								
			 	
						
									

					

	Use of NSAIDS (Aspirin, Tylenol, Motrin)	
		

							
						
							1						
											
										
						
							2						
											
										
						
							3						
											
										
						
							4						
											
								
			 	
						
									

					

	Alcohol consumption makes you feel sick	
		

							
						
							1						
											
										
						
							2						
											
										
						
							3						
											
										
						
							4						
											
								
			 	
						
									

					

	Ulcerative colitis, Crohn's or Celiac disease	
		

							
						
							1						
											
										
						
							2						
											
										
						
							3						
											
										
						
							4						
											
								
			 	
						
							
					
						

					
					
					
					
					
										
		
		
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