Professional Documents
Culture Documents
Patient:
Date:
Date of Birth:
Clinical notes:
Grand Total:
Section 1
This questionnaire is directed at adults only.
25
20
25
10
10
15
15
15
20
20
35
Total Score:
20
(Y/N)
20
10
10
10
Bioregulatory Medicine
BM
Dysbiosis Questionnaire
Section 2
Section 3
1. Fatigue or lethargy
1. Drowsiness
2. Irritability
3. Poor memory
3. Poor coordination
4. Inability to concentrate
5. Depression
6. Headache
7. Muscle aches
7. Dizziness/loss of balance
9. Itching
11. Constipation
11. Heartburn
12. Diarrhea
12. Indigestion
13. Bloating
15. Hemorrhoids
16. Prostatitis
17. Impotence
19. Endometriosis
24. Cough
25. Pain or tightness in chest
26. Wheezing or shortness of breath
7. Urgency or urinary frequency
28. Burning on urination
29. Failing vision
Total Score:
Bioregulatory Medicine
Total Score:
BM