Parasite Questionnaire

Full Name *

Email *

Date *

Instructions

Rate each of the questions to the best of your ability based on your experiences over the past 90 days. Please take note of your scores for each question. Total your score in the space provided at the bottom of the form and compare your results with the rating system.

Do you experience restless sleep (toss or turn, or wake up often)?

Do you have acne, eczema, hives, itching, rashes, skin issues?

Do you have frequent diarrhea or loose stools?

Do you have alternating constipation and diarrhea?

Do you have SIBO (small intestinal bacterial overgrowth), or feel bloated or gassy?

Do you have bowel urgency or occasional accidents?

Do you experience abdominal pains, burning, or cramps?

Do you have rectal and/or anal itching?

Do you have rectal and or anal itching?

Do you have anal fissures (small, painful tears or cracks)?

Do you have stomach or small intestinal ulcers or lesions?

Do you grind your teeth when sleeping?

Do you pick your nose, or have excess boogers in your nose or scab-like boogers?

Do you bite your fingers?

Do you have headaches/migraines?

Are you irritable for no apparent reason?

Do you have a mood disorder, anxiety, depression, or suicidal thoughts?

Do you have hyperactive tendencies (nervousness)?

Do you have dark circles under your eyes?

Do you need extra sleep and wake up unrefreshed?

Do you have allergies and/or food sensitivities?

Do you get fevers of unknown origin?

Do you experience night sweats (not menopausal)?

Do you kiss your pets or allow pets to lick your face?

Do you sleep with pets on your bed?

Do you experience an increase of symptoms around a full moon?

Do you have anemia (low iron/hemoglobin on blood test)?

Do you have iron deficiency?

Do you have vitamin B6 deficiency?

Do you have zinc deficiency and/or white spots on nails?

Do you have frequent colds, flu, or sore throats?

Do you travel in developing nations?

Do you eat pork products?

Do you eat sushi and raw fish?

Do you sleep with pets on the bed?

Do you experience bed-wetting?

Do you frequently vomit?

Do you have a loss of appetite?

Are you hungry all the time, bottomless pit, hungry after meals?

Do you have strong sugar and processed food cravings?

Do you have asthma or breathing problems?

Do you have pain in belly button area (umbilicus)?

Do you have blurry, unclear vision?

Do you have eye floaters?

Do you have lethargy and apathy (disinterest)?

Do you have menstrual problems?

Do you have dry lips?

Do you drool while asleep?

Do you have occult blood in stool (from lab test)?

Do you swim in creeks, lakes, or rivers?

Do you have a history of giardia, pinworms, or other parasites?

Do you work in childcare?

Do you have a history of or currently have cancer?

Parasite Infection Total

Add up your scores and enter the total here

Results

A score in the yellow or red range suggests this area is more likely a problem for you.