Digestive Survey

80% of all diseases and symptoms you have now started in the digestive system. This short questionnaire is not exhaustive, but it does give us clues as to the causes of disease you may be struggling with. Take this free quiz, and let’s find out if you are a candidate for the Living Well Gut Restoration Program.

Please fill out this short survey (including your contact information) so that we can contact you further if needed. Your information will remain safe and confidential.

Rate each of the following based on your health in the last 90 days:

  • 0 = Rarely or never experience the symptom
  • 1 = Occasionally experience but effect is not severe
  • 2 = Occasionally experience but effect is severe
  • 3 = Frequently experience and effect is not severe
  • 4 = Frequently experience and effect is severe
  • 01234
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  • 01234
  • 01234
  • 01234
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  • 01234