Click the "Yes" check box for each question that applies, then click the Calculate Results button at the end of the questionnaire form when you're done to see how you've scored. If you wish to print the questionnaire to fill out later, click on the Printer Friendly link below this side bar.

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   There are fifty-seven questions which give clues to whether or not you have a significant medical cause for your problem.

   If you answer yes to forty of these questions then you have an eighty percent chance of having an underlying, undiagnosed cause for your problems

   If you are in doubt about an answer, please take time to question your family. Sometimes they are unaware or have forgotten about a particular item until their memory is stirred. If you do have an underlying medical problem as a reason for your anorexia or bulimia, wouldn't it make life more enjoyable if the underlying medical problem were corrected and the anorexia or bulimia went away?
1.Do you have any type of abdominal pain?
2.Do you have any type of abdominal pain related to or connected with eating?
3.Do you have abdominal pain which is made worse by eating?
4.Do you have abdominal pain which is relieved or made better by eating?
5.Do you suffer from constipation?
6.Do you suffer from diarrhea?
7.Have you been told that you suffer from an irritable bowel or have irritable bowel syndrome?
8.Do you suffer at different times from constipation alternating with diarrhea?
9.Do you suffer from heartburn?
10.Do you suffer from indigestion?
11.Do you use an antacid, like Tums or Maalox?
12.Does your stomach become distended after you eat?
13.Do you sometimes have trouble buttoning your jeans after eating?
14.Are you gassy?
15.Do you have a history of stomach problems in your family?
16.Do you have a history of gallbladder disease in your family?
17.Do you have a history of gallstones in your family?
18.Does your grandmother in particular have a history of gallbladder disease?
19.Does your aunt have a history of gallbladder disease or gallstones?
20.Does anyone in your family have thyroid disease?
21.Did anyone in your family have a goiter or a big or enlarged neck?
22.Does your mother remember anyone in her family having an enlarged neck?
23.Does anyone in your family have diabetes or low blood sugar?
24.Do you get especially tired at mid-morning?
25.Do you get especially tired or sleepy an hour or so after eating lunch?
26.Do you crave chocolate at times?
27.Does chocolate make you sick?
28.Do you crave a Coke at times?
29.Do you smoke?
30.Have you tried to stop smoking and have been unsuccessful?
31.Do you get tired or sleepy after you eat cake or pastries?
32.Do you ever get a pain in your groin at the skin crease?
33.Do you feel a pulling in your groin after you run the sweeper?
34.Do you feel a pulling in your groin when you turn over in bed?
35.Do you get a pain or a pulling in your groin after you exercise?
36.Do you lose your hair in the comb or hairbrush?
37.Do you lose your hair in the shower after washing your hair?
38.Do you notice hair in the sink after brushing your hair?
39.Is your skin dry?
40.Do you need to use a moisturizer or skin cream?
41.Do you retain fluid?
42.Are your rings tight at times?
43.Have you had to have your rings made larger?
44.Do you remove your rings at night when you go to bed?
45.When you take off your socks is there a ring or indentation around your leg from the elastic?
46.Are your breasts more sore than usual?
47.Have you had to buy a larger bra size?
48.Are your jeans or slacks tighter in the buttock area?
49.Do you notice a puffiness under or around your eyes when you wake up in the morning?
50.Do you wake up tired after taking a nap?
51.Are you forgetful at times?
52.Do you have trouble remembering at times?
53.Do you mind the cold weather?
54.Have you given up any winter sports because of this coldness?
55.Do you wear sweaters when everyone else seems comfortable in lighter clothing?
56.Have you developed a roll of fat just over your beltline?
57.Have you found it impossible to lose this roll of fat no matter how much exercising you do?


Additional Information:
Irritable Bowel Syndrome | Gallbladder Disease
Gallbladder Disease in Children | Depression | Gastroparesis
Insurance & Financial Considerations | Followup Stories

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