Anxiety Symptom and Digestive Response Study Intake Form
Please complete this intake form to help us understand how anxiety symptoms may relate to digestive responses. Your responses are confidential and will be used solely for research purposes.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Age
*
How often do you experience symptoms of anxiety?
*
Never
Rarely
Sometimes
Often
Almost always
Which digestive symptoms do you experience when feeling anxious? (Select all that apply)
Nausea
Stomach pain
Bloating
Diarrhea
Constipation
Loss of appetite
Other
On a scale of 1 to 10, how intense are your digestive symptoms when you feel anxious?
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Have you ever sought professional help for anxiety or digestive issues?
*
Yes, for anxiety only
Yes, for digestive issues only
Yes, for both
No
Which of the following best describes your digestive response to anxiety?
*
Symptoms improve
Symptoms worsen
No noticeable change
Please describe any patterns or triggers you have noticed between anxiety and your digestive symptoms.
Is there anything else you would like us to know regarding your experience with anxiety and digestive symptoms?
Submit
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