TRIOCoaching
Name Email Address Date
Is aimed at assessing lifestyle and gastrointestinal health. The answers can help a person identify problem areas and target treatment accordingly.
Please mark any of the following that you eat regularly:
AlcoholCoffeeFast FoodsCandySoft DrinksSugar & SweetsChewing TobaccoConventional DairyTrans FatsFried FoodsSoy ProductsGluten containing Products
If you drink alcohol, how many drinks per day?
If you drink coffee, how many cups per day?
If you eat fast food, how many times per week?
Do you cook meals at home from scratch?
yesno
How many total meals do you eat at home each week?
How many meals per week do you dine out?
Please describe your current diet:
How many hours a day are you inactive or sitting?
How many times do you exercise per week?
For how long?
Do you sweat when you exercise?
It is heavy or minimal?
How many hours of sleep do you get each night?
Do your feel rested when you wake up in the morning?
Are you currently experiencing high levels of stress?
Rank the amount of stress from 1–10 with 1 being none and 10 being tremendous amounts:
12345678910
Part 2 of this Questionnaire will help a person identify which parts of the digestive tract are causing the most problems or symptoms.
Please enter in the number that best describes the severity of the symptoms listed below. If you do not know the answer then leave it blank. Then add up the totals of the numbers and decide which areas need the most attention.
0 = not present at all
1 = Sometimes occurs with mild severity
2 = Occurs often with moderate severity
3 = Severe and always occurs
Bloating after eating 0123
Food allergies 0123
Poor appetite 0123
Low iron or anemic 0123
Stomach upsets easily 0123
Burping 0123
Constipation 0123
Nausea after taking supplements or eating 0123
Rosacea or acne 0123
Tested positive for candida or parasites 0123
Fullness for extended times after meals 0123
Take antacids 0123
TOTAL
Have a difficult time gaining weight 0123
Tiredness after eating 0123
Multiple food allergies 0123
Shiny stool 0123
Skin issues or acne (not around jawline) 0123
3 or more large bowel movements per day 0123
Dry Skin 0123
Chronic stomach pain on the left side below ribs 0123
Dry or brittle hair 0123
Excessively smelly stools 0123
Nausea 0123
Stool poorly formed 0123
Undigested food in the stool 0123
Slimy stool or mucus in stool 0123
Gallbladder disease or history of gallstones 0123
Vegetables and fiber cause constipation 0123
Acid reflux/heartburn/GERD 0123
Diarrhea 0123
Diabetes 0123
Alternating constipation and diarrhea 0123
Osteoporosis 0123
Flatulence 0123
Alcoholism 0123
Autoimmune condition(s) present 0123
Sourness tastes in mouth regularly 0123
Constant burping, especially after meals 0123
Coughing in the middle of the night 0123
Regurgitating undigested food into the mouth 0123
Heartburn 0123
Burning in the stomach when eating citrus 0123
Have a hard time swallowing food & liquids 0123
Frequent burping and bloating 0123
Regular butterflies in the stomach feeling 0123
Constant abdominal pain 0123
Antacids required for heartburn and/or acid reflux 0123
Pain in the stomach before meals 0123
General stomach pain 0123
Previous use of aspirin or NSAIDS 0123
Black stool (& are not taking iron supplements) 0123
History of previous ulcer 0123
Family history or ulcers or gastritis 0123
Stomach pain relieved by drinking dairy 0123
Carbonated drinks temporarily relieve pain 0123
Frequent indigestion 0123
Pain in stomach occurs when stressed or upset 0123
Have a hard time gaining weight 0123
Halitosis or bad breath 0123
Skin issues or acne 0123
Yellowish tint in the whites of the eyes 0123
Grayish colored skin 0123
Sour taste in the mouth 0123
Hard stool 0123
Not having a daily bowel movement 0123
Foul smelling stool 0123
Pain felt/radiating on the outside of leg 0123
Light colored stool 0123
Pain in the big toe only 0123
Water retention 0123
Painful bowel movements 0123
Have had jaundice or hepatitis 0123
Migraines or headaches after eating 0123
Intolerance to greasy foods 0123
High blood cholesterol and low HDL 0123
Blood in the stool (reddish color) 0123
Cholesterol above 200 0123
Bloating 0123
Have trouble digesting beans and fiber 0123
Have brain fog 0123
Have trouble digesting carbohydrates 0123
Have bad breath 0123
Depressed or anxious all the time 0123
Take antacids (ex. TUMS) 0123
Have sinus congestion 0123
Have food sensitivities/intolerances 0123
Have constipation 0123
Have severe stress 0123
Have chronic diarrhea 0123
Have acid reflux or heartburn 0123
Often get stomach bugs 0123
Have a vitamin D deficiency 0123
Have cramps after you eat 0123
Have arthritis or fibromyalgia 0123
Have mucus or blood in your stool 0123
Taken antibiotics more than twice in the past year 0123
Diagnosed with an autoimmune disease or condition 0123
Currently taking antacids or proton pump inhibitors for heartburn or GERD 0123
Abdominal bloating and distension, especially with carbohydrates such as sugar & fiber 0123
Excessive gas/flatulence 0123
Abdominal pain 0123
Irritable bowel syndrome (IBS) 0123
Fibromyalgia 0123
Restless Leg Syndrome 0123
Intolerance to probiotic supplements and prebiotic fibers 0123
Scored 9 or more on low stomach acid section 0123
Belching or flatulence after eating 0123
Abdominal bloating or swelling 0123
Signs of poor digestion of fatty foods 0123
Weak, peeling or cracked fingernails 0123
Any skin condition 0123
Recurring headaches 0123
Depression, in any form 0123
Fatigue in spite of a good diet and regular sleep 0123
Inability to gain muscle despite weight training 0123
Often eat in a rush 0123
Chew your food properly 0123
Take antacids or acid blocking meds 0123
Have glucose intolerance 0123
Bruise easily (can also be low Vit. K) 0123
Have a B12 deficiency 0123
Ankles swell 0123
Daily bowel movement 0123
Have foul smelling stools 0123
Fullness after a meal 0123
Indigestion after meals 0123
Bloating after meals 0123
Chronic sinus or nasal congestion 0123
Headaches or migraines 0123
History of antibiotic use 0123
Asthma, hay fever or airborne allergies 0123
Chronic and frequent inflammation 0123
Food allergy or food intolerances 0123
Chronic or frequent fatigue or tiredness 0123
Joint pain/swelling/arthritis 0123
Mucus or blood in the stool 0123
Abdominal pain or bloating 0123
Constipation and or diarrhea 0123
Confusion/poor memory/mood swings 0123
Eczema, skin conditions or hives 0123
Ulcerative colitis, Crohn's disease or Celiac disease 0123
Alcohol consumption or alcohol makes you feel sick 0123
Use of nonsteroidal anti-inflammatory drugs (Aspirin, Tylenol, Motrin, Ibuprofen) 0123
Brain fog 0123
Anemic or iron deficiency anemia 0123
Have a hard time losing weight 0123
Achy joints or chronic joint pain 0123
Memory issues 0123
Constipation and/or diarrhea 0123
Bloating and/or gas 0123
Fatigue 0123
Osteoporosis or osteopenia 0123
Get infections easily 0123
History of family history of cancer 0123
Menstrual problems 0123
History of family history of arthritis 0123
Infertility 0123
History of family history of autoimmune disease 0123
Thyroid problems 0123
History of family history of celiac disease 0123
Family history of Inflammatory Bowel Disease 0123
Bladder and kidney infections 0123
Blood or pus in the stool 0123
Frequent and recurrent infections 0123
Recurrent stomach pain 0123
Seasonal or recurring diarrhea 0123
Failing vision 0123
Alternating diarrhea and constipation 0123
Toe and fingernail fungus 0123
Abdominal cramping 0123
Vaginal yeast infections or oral thrush 0123
