Microbiome Questionnaire - drshaynemorris.com

Comprehensive Digestive/Gastro-Intestinal Tract Microbiome Self-Assessment

Enter Doctor's ID*

Select Referring Doctor*

Patient Name*

Patient Gender*

Male
Female

Date of Assessment*

This thorough assessment will help your health professional to better understand the influences that your personal microbiome and your specific Gastro-Intestinal (G.I) processes have on your overall health. This serves as a pre-screening for your health professional to identify exactly which lab tests will be most revealing and which priorities are most applicable to you.

Each topic is stand alone and complete. This means that some questions are applicable more than once because there can be different effects from the same occurrence due to biochemical individuality. You will only have to answer the question one time. Your answer will autofill into the other areas where that same question is relevant.

Your entries are based on your personal knowledge. They are not diagnostic, nor will they be used to diagnose any condition. This is a research questionnaire, reflective of current scientific findings. Please allow 20 minutes to complete.

Medical/Dental History

Do you now, or have ever been, medically/dentally diagnosed to have any of the following? conditions or occurrences?

Achlorhydria (Low Stomach Acid)?*

No
Yes

Acid Esophageal Reflux, Chronic / GERD?*

No
Yes

Acne, Face or Back?*

No
Yes

Acne Rosacea?*

No
Yes

Antibiotic use in last 10 years?*

No
Yes

Anxiety?*

No
Yes

Appendicitis, Appendix Removed?*

No
Yes

Arthritis, Osteo*

No
Yes

Asthma?*

No
Yes

Autoimmune disease (non-thyroid) and/or Rheumatoid Arthritis?*

No
Yes

Barrett’s Disease?*

No
Yes

Birth by Caesarian Section?*

No
Yes

Bronchitis?*

No
Yes

Celiac Disease?*

No
Yes

Chronic Fatigue Syndrome or Adrenal Fatigue?*

No
Yes

Colitis, Ulcerative Colitis?*

No
Yes

Colorectal Cancer?*

No
Yes

Crohn’s Disease?*

No
Yes

Cystic fibrosis?*

No
Yes

Dental Carries (Tooth Decay) in the past 5 years?*

No
Yes

Depression?*

No
Yes

Diabetes?*

No
Yes

Diverticulosis/Diverticulitis?*

No
Yes

Eczema?*

No
Yes

Esophageal or Oral Cancer?*

No
Yes

Esophageal Stricture?*

No
Yes

Esophagitis?*

No
Yes

Fibromyalgia?*

No
Yes

Fissures, Rectal?*

No
Yes

Fistula, Anal?*

No
Yes

Food Poisoning?*

No
Yes

G.I. Infections (Candida, Giardia, Amoeba, H-Pylori, etc.)?*

No
Yes

Gastritis?*

No
Yes

Gastroenteritis (Stomach Flu in past 10 years)?*

No
Yes

Gingivitis (Inflamed Gums)?*

No
Yes

Hay Fever, seasonal or frequent?*

No
Yes

Hashimoto’s or Graves’ Disease?*

No
Yes

Headaches, Migraines?*

No
Yes

Hemorrhoids (Internal, or External)?*

No
Yes

Hiatal Hernia?*

No
Yes

Hyperkeratosis (Skin Rough Patches, Growths)?*

No
Yes

Hyperacidity?*

No
Yes

Hypothyroid?*

No
Yes

Immune deficiency?*

No
Yes

Impotence?*

No
Yes

Infertility?*

No
Yes

Irritable Bowel Syndrome or Disease?*

No
Yes

Kidney/Bladder Infections?*

No
Yes

Perianal Abscesses?*

No
Yes

Polyps, Colon, Rectal?*

No
Yes

Prostatitis?*

No
Yes

Proton pump inhibitor (Rx) currently used?*

No
Yes

Psoriasis?*

No
Yes

Pruritus (Itchy Skin)?*

No
Yes

Spastic Colon?*

No
Yes

Ulcers, Stomach, Intestines?*

No
Yes

Vaginitis?*

No
Yes

More than 1 diagnosis in last 5 years

Section 1 Total*

Oral Microbiome Health

Do you currently use germ-fighting mouthwash?*

No
Yes

Do you currently use fluoride toothpaste?*

No
Yes

Ever used Colgate Total (Triclosan) toothpaste?*

No
Yes

Currently use a toothpaste with Xylitol?*

No
Yes

Currently use a toothpaste with Tea Tree Oil?*

No
Yes

Oil pulling, frequently (not just once or twice)?*

No
Yes

Do you get canker sores (aphthous ulcers)?*

No
Yes

Do you have receding gums?*

No
Yes

Dentist recommended Dental Scaling or Root Planing?*

No
Yes

Gums bleed easily?*

No
Yes

Imprint of your teeth on the edge of your tongue?*

No
Yes

Find hard plaque (calculus) at professional teeth-cleanings?*

No
Yes

Do you drool when you sleep?*

No
Yes

Are you prone to cavities?*

No
Yes

Do you have silver-amalgam (mercury) dental fillings?*

No
Yes

Do you have any root canals?*

No
Yes

Avoid or omit raw, leafy-green vegetables (salads)?*

No
Yes

Drink alcoholic beverages, more than 4 per week?*

No
Yes

Dental abscess in the past 5 years?*

No
Yes

Get dark mucous on your teeth?*

No
Yes

Eat packaged breakfast cereals?*

No
Yes

Eat candy, pies, cakes, cookies?*

No
Yes

Drink sodas (regular or diet)?*

No
Yes

White or yellowish coating on your tongue?*

No
Yes

2-a. Achlorhydria (Low Stomach Acid)?*

No
Yes

2-b. Acid Esophageal Reflux, Chronic / GERD?*

No
Yes

2-c. History of tooth decay?*

No
Yes

2-d. History of oral cancer?*

No
Yes

2-e. G.I. Infections (Candida, Giardia, Amoeba, H-Pylori, etc.)*

No
Yes

2-f. Gingivitis? (Inflamed gums)*

No
Yes

2-g. Hiatal Hernia?*

No
Yes

2-h. Proton pump inhibitor currently used?*

No
Yes

2-i. Ulcers, (Stomach, Intestines)?*

No
Yes

Section 2 Total*

Esophageal Health/Gastro-Esophageal Reflux

Often get heartburn (pyrosis) after meals?*

No
Yes

Heartburn when lying down?*

No
Yes

Heartburn when standing up?*

No
Yes

Does heartburn change your diet?*

No
Yes

Does heartburn wake you from sleep?*

No
Yes

Regurgitation when lying down?*

No
Yes

Regurgitation when standing up?*

No
Yes

Regurgitation after meals?*

No
Yes

Does regurgitation wake you from sleep?*

No
Yes

Does regurgitation change your diet?*

No
Yes

Often have hoarseness?*

No
Yes

Difficulty swallowing (dysphagia)?*

No
Yes

Pain on swallowing?*

No
Yes

Often have to clear your throat?*

No
Yes

Frequent, annoying cough from tickle in throat?*

No
Yes

Teeth erosion?*

No
Yes

Frequent coughing during sleep?*

No
Yes

Bloody or Black Stools?*

No
Yes

Belching, bloating soon after eating?*

No
Yes

Hiccups, frequent or hard to stop?*

No
Yes

Chronic sore throat?*

No
Yes

3-a. Achlorhydria (Low Stomach Acid)?*

No
Yes

3-b. Acid Esophageal Reflux, Chronic / GERD?*

No
Yes

3-c. Anxiety?*

No
Yes

3-d. Asthma?*

No
Yes

3-e. Barrett’s Disease?*

No
Yes

3-f. History of tooth decay?*

No
Yes

3-g. History of esophageal or oral cancer?*

No
Yes

3-h. Esophageal Stricture?*

No
Yes

3-i. Esophagitis?*

No
Yes

3-j. G.I. Infections (Candida, Giardia, Amoeba, H-Pylori, etc.)*

No
Yes

3-k. Gingivitis? (Inflamed gums)*

No
Yes

3-l. Hiatal Hernia?*

No
Yes

3-m. Proton pump inhibitor currently used?*

No
Yes

3-n. Ulcers, (Stomach, Intestines)?*

No
Yes

Section 3 Total*

drshaynemorris.com

Step 1 of 8 - Stage 1

Comprehensive Digestive/Gastro-Intestinal Tract Microbiome Self-Assessment

Medical/Dental History

Oral Microbiome Health

Esophageal Health/Gastro-Esophageal Reflux

General Stomach/Duodenal Health

Stomach, Hyperacidity (Functional Over-Acidity)

Stomach: Hypoacidity (Functional Low Acidity)

Small Intestines: FODMAP (Fermentable Oligosaccharides Disaccharides Monosaccharides And Polyols)

Small Intestines: SIBO (Small Intestinal Bacterial Overgrowth)

Small Intestines: Leaky Gut (Intestinal Hyper-Permeability)

Colon Health

Candida, Small (SIFO) & Large Intestines

Skin Microbiome

Sinus Microbiome

Genital Microbiome: Women Only

Genital Microbiome: Men Only

Inflammation Set Point (Gut/Immune Connection)

Endocrine/Microbiome Connection: Women Only

Endocrine/Microbiome Connection: Men Only

Psychobiome (Gut-Brain Connection)

Gut-Lung Microbiome

General Diet & Lifestyle Factors: Adverse Impact

General Diet & Lifestyle: Beneficial Impact