These questions are designed to highlight symptoms commonly associated with microbiome imbalance or digestive dysfunction. Upon completion, you’ll receive 15% off your first colonic session.This quiz is not intended to diagnose any condition and is for educational purposes only. If you are experiencing persistent or concerning symptoms, we recommend seeking guidance from a qualified healthcare practitioner.

Full Name *

Phone *

Email *

Postal Code *

Have you been diagnosed with "IBS" - Irritable Bowel Syndrome ?

Yes - Medically Diagnosed

Self Diagnosed

Do you experience any of the following skin conditions ?

Eczema

Acne

Rashes

Psoriasis

Hives

None of the above

Do you bloat after eating ?

Yes

Sometimes

Do you have any allergies ? *

Dairy

Gluten

Sugar

Caffeine

Nuts

Seafood

None

How often do you pass stool ?

Daily

3-4 times per week

1-2 times per week

Less than weekly

Can you sleep 8-10 hours uninterrupted ?

Yes

Occasionally

Do you experience any of the following weight related symptoms ?

Excessive weight gain

Excessive weight loss

Stubborn fat

None of the above

Do you experience anxiety ?

Never

Daily

Only related to my menstrual cycle

Only in stressful circumstances

Sometimes

How many courses of antibiotics have you had in your lifetime ?

1-2

3-4

None

Do you experience mood swings ?

Severe

Sometimes

Only related to my menstrual cycle

Never

Do you experience rectum irritation or itching ?

Often

Rare

Never

Please select what applies to your birth & early development ? *

I was predominantly breastfed

I was infant formula fed

I was a caesarean birth

I was a vaginal birth

I'm unsure

Do you have a hormonal imbalance ?

Yes

I suspect

Not sure

Do you consume the following :

Alcohol

Fast Food

Processed Foods

Soft Drinks

Caffeine

Seed Oils

None of the above

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