Functional Digestive Disorder Questionnaire Form
Please complete the Functional Digestive Disorder Questionnaire Form to help us understand your digestive wellness and daily experiences. This form is for informational purposes only and does not collect sensitive or financial information.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
How often do you experience digestive discomfort (such as bloating, gas, or abdominal pain)?
*
Rarely
Occasionally
Frequently
Almost daily
Which of the following digestive symptoms have you noticed in the past month? (Select all that apply)
*
Bloating
Abdominal pain
Gas
Irregular bowel movements
Heartburn
None of these
Other
How would you rate the overall impact of digestive symptoms on your daily life?
*
No impact
1
2
3
4
Severe impact
5
1 is No impact, 5 is Severe impact
How many servings of fruits and vegetables do you eat on a typical day?
*
Please Select
0-1 servings
2-3 servings
4-5 servings
More than 5 servings
How often do you exercise each week?
*
Rarely
1-2 times
3-4 times
5 or more times
How would you describe your stress level over the past month?
*
Low
Moderate
High
Do you have any known food intolerances or allergies?
*
Yes
No
Not sure
Please share any additional comments or observations about your digestive wellness.
Submit
Should be Empty: