Digestive System Intake Form

If any of the following symptoms or activities have occurred within the past three months (unless otherwise specified), please indicate by checking: 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring, or leave blank if the symptom/statement does not apply.
Excessive gas, belching or burping after meals
Stomach bloated after eating
Sleepy after eating
Longitudinal striations on fingernails
Eat when rushed or in a hurry
Halitosis (bad breath)
Full feeling after heavy meat meal
Heavy, tired feeling after eating
Nausea after taking supplements
Undigested food in stool
Yellow or pale fingernails
Oily skin on nose and forehead
Fats/greasy foods cause nausea, headache
Vertical white streaks on fingernails
Onions, cabbage, radishes, cucumbers cause bloating and gas
Bad breath and bad taste in mouth
Excessive body odour
High cholesterol/high cholesterol diet
Stiff, aching muscles
Migraine headaches
Discomfort underneath right ribcage
Food allergies
Irritable, easily angered
Weight gain around the abdomen
Yellow palms
Poor concentration
Difficulty losing weight
Acne, boils, rashes, psoriasis or eczema
Gall stones; history of gall stones
Stool appears clay-colored, foul odoured
High blood cholesterol levels
Severe pain in right upper abdomen
Stomach pain 1 hour after eating or at night
Burning sensation in stomach
Pain aggravated by worry/tension
Hiatal hernia
Gastritis, gastric ulcer
Nausea, vomiting
Sensation of acidity in abdominal area
Heartburn, indigestion
Blood in stool
Lower back pain
Long-term aspirin use
Severe abdominal pain
Slow digestion; feel full for hours after eating
Alcohol addiction
Hungry up to three hours after eating
Strong, sudden cravings for sweets, starches, coffee or alcohol
Nervous, anxious feelings relieved by eating
Irritable if late for or skip a meal
Addicted to coffee with sugar and/or colas
Frequent 'midnight snacks'
Family history of diabetes
Frequent headaches
Fainting spells
Lose temper easily
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