WHAT CAUSED MY SIBO

First Name:

Last Name:

Middle Name:

Date

Email address

IMPAIRED MOTILITY

Autoimmunity

1. You had a case of gastroenteritis/food poisoning/travelers diarrhea lasting for longer than 24 hours?

Yes No

2. Do you have an autoimmune condition?

Yes No

3. Do you have a family history of autoimmunity?

Yes No

Traumatic Brain Injury (TBI)

4. Have you had an injury to the head/spine or whiplash? (Please select))

Horse-riding accident Bike accident Car accident Sporting injury Other

5. Have you ever suffered a concussion?

Yes No

6. Have you ever lost consciousness?

Yes No

7. Have you ever jarred or fallen on your coccyx/tailbone?

Yes No

Thyroid

8. Have you ever been diagnosed with a thyroid disorder?

Yes No

9. Are you on thyroid medication?

Yes No

Diabetes

10. Have you ever been told you have metabolic syndrome, pre-diabetes or diabetes?

Yes No

Chronic Infections

11. Do you have a history of chronic antibiotic use?

Yes No

- Childhood – what for?

- Teen – what for?

- Adult – what for?

Stealth Infections

12. Have you ever been diagnosed with (Please select)

Chronic Fatigue Syndrome Fibromyalgia Chronic viral illness Lyme Disease?

13. Have you been ill after a tick bite?

Yes No

14. Are you allergic to red meat?

Yes No

Mould Toxicity

1. Are you sensitive to mould?

Yes No

2. Do you have mould in your home?

Yes No

3. Have you ever lived in a mouldy home and have not felt well since?

Yes No

Ehlers Danlos Syndrome (EDS)

1. Have you ever been diagnosed with EDS or other hypermobility syndrome?

Yes No

2. Are you double-jointed?

Yes No

Impaired Digestion

0=No 1=mild 2=moderate 3=severe (please select)

3. Do you experience belching or gas within one hour after eating?

0 1 2 3

4. Do you suffer from heartburn or acid reflux?

0 1 2 3

5. Do you have bad breath?

0 1 2 3

6. Do you have trouble digesting meat?

0 1 2 3

7. Do you experience a sense of excessive fullness after meals?

0 1 2 3

8. Do you experience stomach pain or cramping?

0 1 2 3

9. Do you often see undigested food in your stool?

0 1 2 3

10. Do your stools appear greasy or difficult to flush?

0 1 2 3

Impaired Outflow

Abdominal surgeries

11. Do you have a history of any abdominal surgeries such as (please circle)

Removal of appendix Gall bladder Hernia repair

12. Do you have a history of gynaecological issues or surgeries ie: endometriosis, hysterectomy, caesarean, pelvic inflammatory disease, ruptured ovarian cysts, laparoscopy?

Yes No

13. Have you ever been diagnosed with any anatomical abnormalities of your digestive tract? (blind loops, diverticulitis, superior mesenteric artery syndrome)

Yes No

MEDICATIONS

14. Medications you currently take:

15. Medications you have taken in the past:

16. Antidepressants

Yes No

What type:

17. Antispasmodics

Yes No

What type:

18. Opiates or Narcotics

Yes No

What type:

19. Proton pump inhibitors or antacids

Yes No

What type:

20. Cholestyramine

Yes No

21. Antidiarrhoeal medications

Yes No

DO YOU SUFFER FROM ANY OF THE FOLLOWING?

1. Tingling and/or numbness of your hands and/or feet

Yes No

2. Intolerance to light and/or noise

Yes No

3. Bladder irritation/burning urination (Interstitial Cystitis)

Yes No

4. Body ache/body pain (Fibromyalgia)

Yes No

5. Odorous gas (Sulfur odor - rotten egg odor)

Yes No

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