+1 905 780 9908 info@catanzarogroup.com 58 Melbourne Drive Richmond Hill, ON L4S 2V2 Canada

Questionnaire

Step 1

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    Step 2
    Please indicate the appropriate number “0 - 4” on all questions below (0 as never to 4 as always).
    Category 1

    Feeling that bowels do not empty completely

    01234

    Lower abdominal pain relief by passing stool or gas

    01234

    Alternating constipation and diarrhea

    01234

    Diarrhea

    01234

    Constipation

    01234

    Hard dry or small stool

    01234

    Coated tongue or "fuzzy" debris on tongue

    01234

    Pass large amount of foul-smelling gas

    01234

    More than 3 bowel movements daily

    01234

    Use laxatives frequently

    01234

    Category 2

    Excessive belching, burping, or bloating

    01234

    Gas immediately following a meal

    01234

    Offensive breath

    01234

    Difficult bowel movements

    01234

    Sense of fullness during and after meals

    01234

    Difficulty digesting fruits and vegetables

    01234

    Undigested food found in stools

    01234

    Category 3

    Stomach pain, burning or aching 1-4 hours after eating

    01234

    Use antacids frequently

    01234

    Feeling hungry an hour or two after eating

    01234

    Heartburn when lying down or bending forward

    01234

    Temporary relief from antacids, food, milk,
    carbonated
    beverages

    01234

    Digestive problems subside with rest and relaxation

    01234

    Heartburn due to spicy foods, chocolate, citrus, peppers,
    alcohol, and caffeine

    01234

    Category 4

    Roughage and fiber cause constipation

    01234

    Indigestion and fullness lasts 2-4 hours after eating

    01234

    Pain, tenderness, soreness on left side under rib cage

    01234

    Nausea and/or vomiting

    01234

    Excessive passage of gas

    01234

    Stool: undigested, foul smelling, mucous-like,
    greasy, or poorly formed

    01234

    Frequent urination

    01234

    Increased thirst and appetite

    01234

    Difficulty losing weight

    01234

    Category 5

    Greasy or high-fat foods cause distress

    01234

    Lower bowel gas and or bloating several hours
    after eating

    01234

    Bitter metallic taste in mouth especially in the morning

    01234

    Unexplained itchy skin

    01234

    Yellowish cast to eyes

    01234

    Stool color alternates from clay-colored to normal brown

    01234

    Reddened skin, especially palms

    01234

    Dry or flaky skin and/or hair

    01234

    History of gallbladder attacks or stones

    01234

    Have you had your gallbladder removed?

    01234

    Category 6

    Crave sweets during the day

    01234

    Irritable if meals are missed

    01234

    Depend on coffee to keep yourself going or started

    01234

    Get lightheaded if meals are missed

    01234

    Eating relieves fatigue

    01234

    Feel shaky, jittery, tremors

    01234

    Agitated, easily upset, nervous

    01234

    Poor memory, forgetful

    01234

    Blurred vision

    01234

    Category 7

    Fatigue after meals

    01234

    Crave sweets during the day

    01234

    Eating sweets does not relieve cravings for sugar

    01234

    Must have sweets after meals

    01234

    Waist girth is equal or larger than hip girth

    01234

    Frequent urination

    01234

    Increased thirst and appetite

    01234

    Difficulty losing weight

    01234

    Category 8

    Cannot stay asleep

    01234

    Crave salt

    01234

    Slow starter in the morning

    01234

    Afternoon fatigue

    01234

    Dizziness when standing up quickly

    01234

    Afternoon headaches

    01234

    Headaches with exertion or stress

    01234

    Weak nails

    01234

    Category 9

    Cannot fall asleep

    01234

    Perspire easily

    01234

    Under high amounts of stress

    01234

    Weight gain when under stress

    01234

    Wake up tired even after 6 or more hours of sleep

    01234

    Excessive perspiration or perspiration with little or no activity

    01234

    Category 10

    Tired, sluggish

    01234

    Feel cold - hands, feet, all over

    01234

    Require excessive amounts of sleep to function properly

    01234

    Increase in weight gain even with low-calorie diet

    01234

    Gain weight easily

    01234

    Difficult, infrequent bowel movements

    01234

    Depression, lack of motivation

    01234

    Morning headaches that wear off as the day progresses

    01234

    Outer third of eyebrow thins

    01234

    Thinning of hair on scalp, face or genitals, or
    excessive falling hair

    01234

    Dryness of skin and/or scalp

    01234

    Mental sluggishness

    01234

    Category 11

    Heart palpations

    01234

    Inward trembling

    01234

    Increased pulse even at rest

    01234

    Nervousness and emotional

    01234

    Insomnia

    01234

    Night sweats

    01234

    Difficulty gaining weight

    01234

    Category 12

    Diminished sex drive

    01234

    Menstrual disorders or lack of menstruation

    01234

    Increased ability to eat sugars without symptoms

    01234

    Category 13

    Increased sex drive

    01234

    Tolerance to sugars reduced

    01234

    "Splitting" type headaches

    01234

    Category 14 (Males Only)

    Urination difficulty or dribbling

    01234

    Frequent urination

    01234

    Pain inside of legs or heels

    01234

    Feeling of incomplete bowel evacuation

    01234

    Leg nervousness at night

    01234

    Category 15 (Males Only)

    Decrease in libido

    01234

    Decrease in spontaneous morning erections

    01234

    Decrease in fullness of erections

    01234

    Difficulty maintaining morning erections

    01234

    Spells of mental fatigue

    01234

    Inability to concentrate

    01234

    Episodes of depression

    01234

    Muscle soreness

    01234

    Decrease in physical stamina

    01234

    Unexplained weight gain

    01234

    Increase in fat distribution around chest and hips

    01234

    Sweating attacks

    01234

    More emotional than in the past

    01234

    Category 16 (Menstruating Females Only)

    Are you menopausal?

    01234

    Alternating menstrual cycle lengths

    01234

    Extended menstrual cycle, greater than 32 days

    01234

    Shortened menses, less than every 24 days

    01234

    Pain and cramping during periods

    01234

    Scanty blood flow

    01234

    Heavy blood flow

    01234

    Breast pain and swelling during menses

    01234

    Pelvic pain during menses

    01234

    Irritable and depressed during menses

    01234

    Acne breakouts

    01234

    Facial hair growth

    01234

    Hair loss/thinning

    01234

    Category 17 (Menopausal Females Only)

    How many years have you been menopausal?

    01234

    Do you ever have uterine bleeding since menopause?

    01234

    Hot flashes

    01234

    Mental fogginess

    01234

    Disinterest in sex

    01234

    Mood swings

    01234

    Depression

    01234

    Painful intercourse

    01234

    Shrinking breasts

    01234

    Facial hair growth

    01234

    Acne

    01234

    Increased vaginal, pain, dryness, or itching

    01234

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