LEAKY GUT QUESTIONNAIRE

YES NO

1. Have you gained weight and no diet seems to work? ☐ ☐

2. Do you have chronic postnasal drip with thick mucus? ☐ ☐

3. Do you often develop mouth ulcers? ☐ ☐

4. Have you been diagnosed with chronic sinusitis? ☐ ☐

5. Do you have chronic bad breath or halitosis? ☐ ☐

6. Do you have nasal or sinus polyps? ☐ ☐

7. Have you been diagnosed with eczema? ☐ ☐

8. Do you get hives or urticaria from time to time? ☐ ☐

9. Have you been diagnosed with irritable bowel syndrome? ☐ ☐

10. Do you have frequent heartburn or acid reflux? ☐ ☐

11. Have you been diagnosed with Crohn’s disease or ulcerative colitis? ☐ ☐

12. Do you have a history of migraines or headaches? ☐ ☐

13. Have you been diagnosed with chronic fatigue syndrome and/or fibromyalgia? ☐ ☐

14. Have you been diagnosed with ADD, ADHD, or autism? ☐ ☐

15. Do you have a history of PMS? (women only) ☐ ☐

16. Do you have recurring vaginal itching or discharge? (women only) ☐ ☐

17. Have you been diagnosed with degenerative arthritis? ☐ ☐

18. Have you been diagnosed with mitral valve prolapse? ☐ ☐

19. Do you feel tired after meals? ☐ ☐

20. Do you have frequent bloating and gas after eating? ☐ ☐

Points for each “yes” answer:

Questions 1 to 20: 2 points each.

Total: ________

Precision nutrition