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Environmental poisoning can put your health in jeopardy. Thorne Research offer a range of products designed to help rid your body of these toxins.

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Here is a great way to assess your health needs. We provide health questionnaires to help you identify problem areas within your health.

Health Questionnaires

Candida | Gluten Sensitivity | Food Allergies | Hypoglycemia

(All information is held in strict confidentiality and will not be shared or sold)

GLUTEN SENSITIVITY QUESTIONNAIRE

Full Name:
Email Address:
Confirm Email Address:
Phone:

Age:

Sex:

Weight:

Height:

Conditions: Check each symptom according to its severity.

Symptom:	Never	Occasional But Mild in Intensity	Frequent But Mild in Intensity	Occasional But Moderate-to-Severe	Frequent and Moderate-to-Severe
1. Recurrent mouth ulceration, canker sores ?
2. Reddened, swollen, painful tongue ?
3. Abdominal pain and cramping ?
4. Pain around your naval, made worse by eating ?
5. Intestinal gas, flatulence ?
6. Diarrhea of an unexplained cause ?
7. Constipation of an unexplained cause ?
8. Stools that are pale, soft, bulky, floating or difficult to flush ?
9. Foul smelling, frothy stools, often with excess fat droplets or globules ?
10. Bloody or black, tarry stools of unknown cause ?
11. Nausea and vomiting of an unexplained cause ?
12. Unintentional progressive weight loss ?
13. Unintentional weight gain ?
14. Depressed mood, often with irritability, for no apparent reason ?
15. Bone pain or tenderness ?
16. Joint pain or tenderness ?
17. Muscle aches and pain ?
18. Migraine-like headaches ?
19. Fatigue or lack of energy ?
20. Intensely itchy, blistering skin rash ?
21. Internal hemorrhaging or easy bruising for no apparent reason ?

By checking this box, I am giving permission for the results of this questionnaire to be sent to Dr. Patricia Bender and to be contacted by her to discuss them

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