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Leaky Gut Assessment

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Intestinal Permeability or Leaky Gut is real and defined as a condition where the lining of the small intestine becomes damaged, causing undigested food particles, toxic wastes and bacteria to "leak" through the intestines and flood the bloodstream setting off a cascade of protective immune responses. One reason why leaky gut has been hard to identify is that its bodily impact is not limited to the gastrointestinal tract – it impacts the brain, thyroid, immune system, skin, and joints and varies based on a person’s genetic and epigenetic expressions.

This Assessment presents questions that your healthcare practitioner can use to determine if further testing for leaky gut is warranted. Assessment brought to you by Dr. Jack Tips (Ph.D., C.C.N.).

First name
Last name
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Frequent constipation?

Frequent diarrhea?

Medically diagnosed with: IBS, GERD, Crohn’s, Diverticulitis, Ulcerative Colitis?

Often find blood in stool?

Abdominal pain after eating?

Food Sensitivities?

Belching, frequent?

Bloating after eating, drinking (more than once a week)?

Food allergies, several?

Food intolerance

Gas, frequent, foul?

Heartburn?

Chronic Fatigue?

Energy drops after eating?

Often feel stressed?

Anxiety, feel anxious?

Depression?

Forgetfulness?

Difficulty focusing thoughts?

Acne?

Dry patches not responsive to topical moisturizers

Eczema

Hives

Itchy skin, without eruptions

Rosacea

Female: PMS

Male: Enlargement of breast tissue?

Female & Male: Cherry Angiomas (little red dots in the skin)

Any Autoimmune Issue (Arthritis, Asthma Celiac, Diabetes I, Hashimotos, Lupus, Multiple Sclerosis, Myasthenia Gravis, etc.?

Antibiotic, used in past 10 years?

Rx NSAID, in the past 5 years?

Aspirin, in the past 4 years?

Ibuprofen, in the past 4 years?

Tylenol, in the past 4 years?

Alcohol—consume 4+ beverages/week?

Less than 6-hrs, sleep/night?

High starch/sugar/sweets diet

Crave sweets 

Eat Fast Foods, 2 or more times/week?

Use processed, packaged foods 2 or more times/week?

Consume GMO foods (corn, soy, canola oil, Hawaiian (rainbow) papayas, potatoes, Arctic apples yellow crookneck ‘summer’ squash, zucchini, sugar beets, alfalfa)?

Consume sodas and/or sugar-free sodas?

Consume sugar-free foods (AspartameTM)?

Exercise less than 4 times a week?

Allergies: Environment Allergies, Animals, Perfumes aggravates, Pollens, Dust?

Bad Breath even after brushing

Joint/Muscle Pain after eating certain foods, e.g. nightshades (tomatoes, potatoes, peppers eggplant, gogi berries,)?

Frequent post-nasal drainage

Frequent sinus infections

Ongoing nasal congestion



Disclaimer: This personal assessment is not diagnostic of any health condition. It is designed to help licensed health practitioners organize varied body occurrences that, when viewed as an organized whole, may lead to a common factor.