Gastrointestinal Assessment Questionnaire
Please complete this questionnaire to help us better understand your gastrointestinal symptoms and related health factors.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email
*
example@example.com
Please indicate how often you experience the following symptoms:
*
Rows
Never
Rarely
Sometimes
Often
Always
Abdominal pain
1
2
3
4
5
Nausea
6
7
8
9
10
Vomiting
11
12
13
14
15
Diarrhea
16
17
18
19
20
Constipation
21
22
23
24
25
Bloating or gas
26
27
28
29
30
Heartburn or acid reflux
31
32
33
34
35
Have you ever been diagnosed with any of the following gastrointestinal conditions?
Irritable Bowel Syndrome (IBS)
Inflammatory Bowel Disease (IBD)
Celiac Disease
Peptic Ulcer
Lactose Intolerance
None of the above
Other
Are you currently taking any medications for gastrointestinal symptoms?
*
Yes
No
Do you have any of the following red flag symptoms? (Select all that apply)
*
Unintentional weight loss
Blood in stool
Severe or persistent vomiting
Difficulty swallowing
Persistent fever
None of the above
Please rate your typical abdominal pain on a scale of 1 (no pain) to 10 (worst pain imaginable).
*
No pain
1
2
3
4
5
6
7
8
9
Worst pain
10
1 is No pain, 10 is Worst pain
Family history: Has any blood relative been diagnosed with a gastrointestinal disease?
Yes
No
Not sure
How would you describe your typical diet?
Please Select
Balanced (includes fruits, vegetables, protein, grains)
High in processed foods
Vegetarian/Vegan
Low fiber
Other
Do you smoke or use tobacco products?
Yes
No
Former user
Do you consume alcohol?
Never
Occasionally
Regularly
Please provide any additional information or concerns about your gastrointestinal health.
Submit Questionnaire
Should be Empty: