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Scienta Q-Gap Questionnaire
What is Your Q Gap Score?

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   Frequency
of
Symptoms 		  Intensity
of
Symptoms 
 Body
 System 		  Symptoms    if you scored
frequency 1-3
 Head and Neck  almost
never		 occasional moderate almost
always		 mild moderate severe
0 1 2 3 1 2 3
 Brain   headaches/migraines
    light headedness
 Eyes   watery or discharging
    dry, itchy or sore
    red
    blurred/deteriorating vision
 Ears   ringing/pain in ear
    deteriorating hearing
 Nasal   congestion
    runny nose/nasal discharge/post nasal drip
    bleeding nose
    deteriorating smell
 Mouth/Throat   dry mouth
    itchy throat
    feeling of lump in throat
 Gastro-Intestinal  almost
never		 occasional moderate almost
always		 mild moderate severe
0 1 2 3 1 2 3
    lack of appetite/hunger
    unexplained weight changes (loss or gain)
    difficulty gaining weight
    cravings
    difficulty losing weight
    bad breath
    bitter/metallic/abnormal/loss of taste
    chewing or swallowing difficulties/pain on swallowing
    nausea or vomiting
    indigestion, reflux, heartburn
    bloating or passing gas
    constipation
    diarrhea
    blood in stool
    abdominal pain
 Cardio-Respiratory  almost
never		 occasional moderate almost
always		 mild moderate severe
0 1 2 3 1 2 3
 Lung   breathlessness at rest
    breathlessness on mild or periodic exertion e.g. walking
    wheezing
    coughing
    low endurance/stamina when sedentary
    low endurance/stamina on periodic exertion e.g. walking
    low endurance/stamina in sport-like/athletic activity
 Cardiovascular   chest tightness/pain
    abnormal heart rhythm/pronounced heartbeat
    rapid/racing heart rate
    low heart rate <40 per min
    swelling of ankles, feet and hands
   Frequency
of
Symptoms 		  Intensity
of
Symptoms 
 Body
 System 		  Symptoms    if you scored
frequency 1-3
 Musculoskeletal  almost
never		 occasional moderate almost
always		 mild moderate severe
0 1 2 3 1 2 3
 Muscles   muscle aches/pain
    muscle cramping/seizing
    involuntary muscle control or muscle twitching
    reduced muscle strength/physical weakness
 Joints   joint pains
    joint stiffness/lack of flexibility
    joint swelling
    lack of mobility with mild exertion e.g. short walk
    lack of mobility with moderate activity e.g. brisk walk
    neck spasms/pain
    back spasms/pain
 Neurological  almost
never		 occasional moderate almost
always		 mild moderate severe
0 1 2 3 1 2 3
    tremors/shakes
    numbness/tingling sensation
    poor physical co-ordination
    sense of hyperactivity/restlessness
    nervousness/irritability
    feeling fatigued/sluggish
    dizziness
    fainting/loss of consciousness spells
    convulsions/seizures
    hot flashes/flushes
    night sweats
    speech difficulty
 Uro/Gynecological  almost
never		 occasional moderate almost
always		 mild moderate severe
0 1 2 3 1 2 3
    frequent urination - all day
    frequent urination - nights only
    involuntary leakage of urine/loss of bladder control
    pain on urination (burning)/bloody urination
    painful sexual experience
    loss of sex drive
    orgasm difficulties
    pelvic pain
    slow urinary stream
    lack of ability to urinate (urinary retention)
    erection difficulties
    heavy/crampy menstrual cycles
    vaginal dryness
    vaginal discharge/itching
   Frequency
of
Symptoms 		  Intensity
of
Symptoms 
 Body
 System 		  Symptoms    if you scored
frequency 1-3
 Skin and Hair  almost
never		 occasional moderate almost
always		 mild moderate severe
0 1 2 3 1 2 3
 Skin   dry or itchy skin, flaky skin
    bruising/hematomas
    oily skin/acne
    rashes/hives
    water retention/puffiness
    excessive body hair
    body odor
 Hair and Scalp   hair thinning/loss (non-genetic)
    dry hair
    excessive dandruff
    oily hair
    crusting/blisters/bumps on scalp
 Emotional Health  almost
never		 occasional moderate almost
always		 mild moderate severe
0 1 2 3 1 2 3
    memory lapses
    difficulty thinking or concentrating
    indecisiveness
    moments of confusion
    lack of interest in day to day
    feelings of sadness/depression
    panic/anxiety, fears or phobias
    suicidal thoughts
    fidgety, restless/unable to sit still
    feelings of frustration
    mood swings
    temper/angry outbursts
    sense of invincibility/mania
    too much sleep
    too little sleep
    insomnia - difficulty falling asleep/staying asleep
    disturbed sleep/bad dreams
    recurring thoughts/obsessions/compulsions
 Psycho-Social Issues  almost
never		 occasional moderate almost
always		 mild moderate severe
0 1 2 3 1 2 3
    unhappiness/frustration in relationship with spouse/partner
    unhappiness/frustration in relationship with family members
    unhappiness/frustration in relationship with friends
    unhappiness/frustration in relationship with professional associates
    lack of sense of purpose in personal life
    lack of sense of purpose in family life
    lack of sense of purpose in social life
    lack of sense of purpose in professional life
    emotional pressures in professional workplace
    emotional pressures in marriage
    emotional pressures in parents
    emotional pressures in children
    emotional pressures in friends
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