My Questionnaire | Gut Health Monitor

Demographic Data

1. Aggressive Behaviors

ಹೆಸರು / Name

ಲಿಂಗ / Sex

ಹುಟ್ಟಿದ ಸ್ಥಳ / Place of Birth

ಹುಟ್ಟಿದ ದಿನಾಂಕ / Date of Birth

ವಯಸ್ಸು / Age

ದೂರವಾಣಿ / Phone

ಇಮೇಲ್ / Email

ರೋಗನಿರ್ಣಯ / Diagnosis

ಕೇಸ್ ಇತಿಹಾಸ / Case History

ವಸ್ತುನಿಷ್ಠ ಜಾಗತಿಕ ಮೌಲ್ಯಮಾಪನ / Subjective Global Assessment

ಮೊದಲ 1000 ದಿನಗಳು / First 1000 Days

Was your baby fed during the golden hour?

ಹೌದು / Yes

ಇಲ್ಲ/ No

Was the baby able to latch

ಹೌದು / Yes

ಇಲ್ಲ/ No

Was your baby exclusively breastfed for 6 months

ಹೌದು / Yes

ಇಲ್ಲ, ಕಾರಣ ನೀಡಿ / No, give the reason

ಕಾರಣ / Reason

Was your baby fed on formula

ಹೌದು, ಎಷ್ಟು ದಿನಗಳು / Yes, How long?

ಇಲ್ಲ/ No

ವಿವರವನ್ನು ಒದಗಿಸಿ / Mention It

ನಿಮ್ಮ ಮಗುವಿಗೆ ಎಷ್ಟು ದಿನಗಳು ಹಾಲುಣಿಸಿದಿರಿ? / How long was your baby breastfed?

ಯಾವ ವಯಸ್ಸಿನಲ್ಲಿ ಹಾಲುಣಿಸುವಿಕೆಯನ್ನು ಪ್ರಾರಂಭಿಸಲಾಯಿತು? / At what age was the weaning started?

ಹಾಲುಣಿಸುವಿಕೆಯ ಪ್ರಕಾರ ಯಾವುದು? / What was the type of weaning?

ಯಾವುದೇ ಕೊಲಿಕ್ (ಹೊಟ್ಟೆ ನೋವಿನ) ಸಮಸ್ಯೆಗಳಿವೆಯೇ? / Were there any colic issues?

ತರಬೇತಿ ಯಾವಾಗ ಪ್ರಾರಂಭವಾಯಿತು? / When was the potty training started?

Anthropometric

ಎತ್ತರ / Height

ತೂಕ / Weight

ತಲೆಯ ಸುತ್ತಳತೆ / Head Circumference

MUAC

SFT

BMI Percentile

BMR

Biochemical

ಹಿಮೋಗ್ಲೋಬಿನ್ / Hemoglobin

Clinical

ಸಾಮಾನ್ಯ ಗೋಚರತೆ / General Appearance

ಸಬ್ಕ್ಯುಟೇನಿಯಸ್ ಕೊಬ್ಬಿನ ನಷ್ಟ / Loss of subcutaneous fat

ಮುಳುಗಿದ ಅಥವಾ ಟೊಳ್ಳಾದ ಕೆನ್ನೆಗಳು / Sunken or Hollow Cheeks

ಕೂದಲು / Hair

ಒಣ ಕೂದಲು / Dry Brittle Hair

Corkscrew Hair

ಉಗುರುಗಳು / Nails

Spooning

Transverse Lines

ಚರ್ಮ / Skin

ಒಣ ಮತ್ತು ಚಿಪ್ಪುಗಳುಳ್ಳ / Dry and scaly

Pallor

Dietary

Day Recall

ಉಪಹಾರ / Breakfast

ಮಧ್ಯಾಹ್ನ ಊಟ / Lunch

ತಿಂಡಿಗಳು / Snacks

ರಾತ್ರಿ ಊಟ / Dinner

Food Frequency Questionnaire

ಧಾನ್ಯಗಳು: ದೈನಂದಿನ / Cereals: Daily

Cereals: ಸಾಪ್ತಾಹಿಕ / Weekly

Cereals: ಆಗಾಗ್ಗೆ / Often

Cereals: ಅಪರೂಪಕ್ಕೆ / Rarely

Rice : Daily

Rice : Weekly

Rice : Often

Rice : Rarely

Ragi : Daily

Ragi : Weekly

Ragi : Often

Ragi : Rarely

Wheat : Daily

Wheat : Weekly

Wheat : Ofetn

Wheat : Rarely

Jowar : Daily

Jowar : Weekly

Jowar : Often

Jowar : Rarely

Pulses : Daily

Pulses : Weekly

Pulses : Often

Pulses : Rarely

Milk and milk products : Daily

Milk and milk products : Weekly

Milk and milk products : Often

Milk and milk products : Rarely

Vegetables : Daily

Vegetables : Weekly

Vegetables : Often

Vegetables : Rarely

Fruits : Daily

Fruits : Weekly

Fruits : Often

Fruits : Rarely

Meat : Daily

Meat : Weekly

Meat : Often

Meat : Rarely

Packed food/ Ultra processed foods : Daily

Packed food/ Ultra processed foods : Weekly

Packed food/ Ultra processed foods : Often

Packed food/ Ultra processed foods : Rarely

Gut Health

Does your child experience constipation?

How often is your child brain fogged?

• Does your child feel nauseous, if yes how often. Is there any food /s trigger it?

• Do you see any changes in eating pattern after a panic attack? Can it be described

• Does your child complain about heart burn and abdominal pain

• Do you notice irregularities in breathing?

Is the child diagnosed with IBS?

• Do you find your child ruminating often?

• Do you notice regurgitation of recently ingested food?

• Does the child experience pain on stooling?

Smelly stool?

How often do they fall sick?

Any recent antibiotic usage?

Any food allergy?

Any self- mutilation?

Does the child get a sound sleep?

Problem Behaviour Checklist R

I Aggressive Behaviors

Hits or Punches others

Punches others

Pinches others

Pulls hair / ear / body parts of others

Slaps others

Kicks others

Spits on others

Bites others

Attracks or pokes others with weapons

Throws objects at others

Cruel on animals for no reason

II Destructive Behaviors

Bangs objects

Slams doors

Tears up clothes, books, papers or magazines

Damages furniture

Fire-setting

III Repetitive Behaviors: Self Injurious

Bangs Head

Bites Self

Cuts or mutilaes self

Pulls own Hair

Hits Self

Scratches Self

Peels skin/wounds

Threatens to kill oneself

Puts objects into eye/nose/ear

IV Repetitive Behaviors: Non-Injurious

Bites nails

Sucks thumb

Shakes parts of body

Rocks body

Swings round and round

Grinds teeth

Makes peculiar Sounds

Bites end of pen/pencil

Overuses cell phones

VII Repetitive Behaviors: Odd

Laughs to self inappropriately

Talks to self

Hoards unwanted objects (sticks, throad, pieces of cloth)

Plays with unwanted objects like slippers, strings, dirt, feces

Kisses, hugs and licks people unnecessarily

Smells objects

Picks Nose

VI Repetitive Behaviors: Odd

Hoards unwanted objects (sticks, throad. pieces of cloth)

Laughts to self inaapropriately

Talks to self

Plays with unwanted object like slippers, strings, dirt, feces

Hoards unwanted objects (sticks, throad. pieces of cloth)

Kisses, hugs and licks people unnessarily

Smells objects

Picks Nose

VI AntiSocial Behaviors: Odd

Lies or twists the truth to his own advantage or blames others

Cheats in games or no sense of fair play

Steals

Pawns things to get money

Extots money/things from others

Runs away from School

Touches own private parts in public

Makes obsence gestures

Make sexual advances towards members of opposite ses

Dropdown

Touches others private parts in public

Gambles

Uses alcohol, tobocca or drugs

VII Mesbehaviors with others: Odd

Pulls objects from others

Takes others possesslons without their permission openly

Makes loud noise when others are working or reading

Interrupts in between when others are talking

Uses abusive/vulgar language

Forces others to do according to his/her way (bossy)

Intimidates others

Argues without purpose

Passes unwanted comments on others

Stares at others

Makes face to tease others

Laughs or mocks at others

Trips others when they are walking across

Gossips/spreads rumors about others

Writes nasty things about others

VIII Rebellious Behaviorss: Odd

Refuses to obey commands

Does opposite of what is requested

Takes very long time intentionally to complete given task

Wanders outside classroom

IXTemper Tantrums: Odd

Cries excessively

Screams

Stamps foot

Rolls on floor

X Hyperactivity : Odd

Does not sit at one place requried time

Does not ........to pay attention to what is taid

Does not continue with the task at and required time

XIActivities of Daily Living : Odd

Overeats

Underreats

Eats Inedible Items

Sleep related Issues

Passes urine at Inappropriate Places

Passes Feces at Inappropriate Places

XIII Emotional: Odd

Fear of Objects

Fear of Animals

Fear of Places

Fear of Persons

Sad

Shy

Self Concious or

Easily Embrassed

XIII Others: Odd

Postpones Things Frequenlty

Slow and Tardy/Falls to Complete Work Time

Keeps Things Untidy

Complains of Body Aches/other signs of ill Health

Stammers / Stutters

Refuses to Speak in Some Situations / With Some Persons

RefusSpeakes in Ladies Voice (boys) in Male Voice (girls)

Users Bay Talk / Behaves immature

Boasts / Brags oe Shows off

Can't get his mind of Certain Thoughts (Observations)

DOMAIN: Odd

1. Agree Behaviours

2. Destructive Behaviours

3. Repetitative Behaviours : Self-Injurious

4. Repective Behaviours : Non-Injurious

5. Repective Behaviour : Odd

6. Antisocial Behaviours with others

7. Misbehaviors with Others

8. Rebelliors Behaviours

9. Temper Tantrums

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