LEAKY GUT QUESTIONAIRE
Constipation and/or diarrhea
0 = Symptom is not present or rarely present
1 = Mild/sometimes
2 = Moderate/often
3 = Severe/almost always
Abdominal pain or bloating
0 = Symptom is not present or rarely present
1 = Mild/sometimes
2 = Moderate/often
3 = Severe/almost always
Mucous or blood in stool
0 = Symptom is not present or rarely present
1 = Mild/sometimes
2 = Moderate/often
3 = Severe/almost always
Joint pain or swelling, arthritis
0 = Symptom is not present or rarely present
1 = Mild/sometimes
2 = Moderate/often
3 = Severe/almost always
Chronic or frequent fatigue or tiredness
0 = Symptom is not present or rarely present
1 = Mild/sometimes
2 = Moderate/often
3 = Severe/almost always
Food allergies, sensitivities or intolerance
0 = Symptom is not present or rarely present
1 = Mild/sometimes
2 = Moderate/often
3 = Severe/almost always
Sinus or nasal congestion
0 = Symptom is not present or rarely present
1 = Mild/sometimes
2 = Moderate/often
3 = Severe/almost always
Chronic or frequent inflammations
0 = Symptom is not present or rarely present
1 = Mild/sometimes
2 = Moderate/often
3 = Severe/almost always
Eczema, skin rashes or hives (urticaria)
0 = Symptom is not present or rarely present
1 = Mild/sometimes
2 = Moderate/often
3 = Severe/almost always
Asthma, hay fever, or airborne allergies
0 = Symptom is not present or rarely present
1 = Mild/sometimes
2 = Moderate/often
3 = Severe/almost always
Confusion, poor memory or mood swings
0 = Symptom is not present or rarely present
1 = Mild/sometimes
2 = Moderate/often
3 = Severe/almost always
Use of NSAIDS (Aspirin, Tylenol, Motrin)
0 = Symptom is not present or rarely present
1 = Mild/sometimes
2 = Moderate/often
3 = Severe/almost always
History of antibiotic use
0 = Symptom is not present or rarely present
1 = Mild/sometimes
2 = Moderate/often
3 = Severe/almost always
Alcohol consumption makes you feel sick
0 = Symptom is not present or rarely present
1 = Mild/sometimes
2 = Moderate/often
3 = Severe/almost always
Ulcerative colitis, Crohn’s or celiac disease
0 = Symptom is not present or rarely present
1 = Mild/sometimes
2 = Moderate/often
3 = Severe/almost always
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