Leaky Gut Syndrome Questionnaire

First Name

Email Address

Last Name

Date of Birth

Check the number that most closely fits, then add up the results.

0= Symptom not present or rarely present

1= Mild /Sometimes

2= Moderate/Often

3= Severe/Almost always

Constipation and/or diarrhea

1

2

3

4

Joint pain or swelling, arthritis

0

1

2

3

Food allergies, sensitivities or intolerance

0

1

2

3

Chronic or frequent inflammations

0

1

2

3

Confusion, poor memory or mood swings

0

1

2

3

Asthma, hayfever, or airborne allegies

0

1

2

3

Mucous or blood in stool