Gut Symptoms Questionnaire

Name*
Email*
example@example.com
Today's Date

DayMonthYear
Age*
Sex*

FemaleMalePrefer not to say
Country of residence*
Health concerns

Type 2 DiabetesHigh Blood pressureHeart Disease (any)Autoimmune conditions like Psoriasis, Rheumatoid ArthritisIBSKidney DiseaseMental health challengesOther
If you have an autoimmune condition, please specify your diagnosis.
Food
Please list all the food and drinks you consume regularly*
Meals per day (Excluding snacks)*

1234Other
Snacks per day*

I don't snack1234Other
First food or drink intake of the day. (Water, black tea, coffee without sweeteners are excluded)*

:HourMinutesAM/PM Option
Last food or drink intake of the day. (Water, black tea, coffee without sweeteners are excluded) *

:HourMinutesAM/PM Option
Gut Symptoms

Please rate your experience of the following symptoms over the last 2-4 weeks. 0=Symptom is infrequent or absent. 10=Symptom is very frequent or unbearable.

Recurrent abdominal (stomach) pain. Dull aching diffuse pain, commonly in the lower abdomen. Sometimes acute pain in addition to dull pain.*

	0	1	2	3	4	5	6	7	8	9	10

0 is Infrequent or absent, 10 is Very frequent or unbearable

Pain relieved by defecation (passing stools)*

	0	1	2	3	4	5	6	7	8	9	10

0 is Infrequent or absent, 10 is Very frequent or unbearable

A feeling of incomplete evacuation*

	0	1	2	3	4	5	6	7	8	9	10

0 is Infrequent or absent, 10 is Very frequent or unbearable

Eating food worsens the pain*

	0	1	2	3	4	5	6	7	8	9	10

0 is Infrequent or absent, 10 is Very frequent or unbearable

Bloating or distention or “gassy” feeling*

	0	1	2	3	4	5	6	7	8	9	10

0 is Infrequent or absent, 10 is Very frequent or unbearable

Have to visit the toilet soon after eating food*

	0	1	2	3	4	5	6	7	8	9	10

0 is Infrequent or absent, 10 is Very frequent or unbearable

Passage of mucus *

	0	1	2	3	4	5	6	7	8	9	10

0 is Infrequent or absent, 10 is Very frequent or unbearable

Constipation. Difficulty passing stools or infrequent or hard stools*

	0	1	2	3	4	5	6	7	8	9	10

0 is Infrequent or absent, 10 is Very frequent or unbearable

Diarrhea. Loose motion, watery stools, maybe several times a day*

	0	1	2	3	4	5	6	7	8	9	10

0 is Infrequent or absent, 10 is Very frequent or unbearable

Bowel Movement Consistency

Cabot Health, Bristol Stool Chart, CC BY-SA 3.0 , via Wikimedia Commons
Type 1Type 2Type 3Type 4Type 5Type 6Type 7

Constipation alternating with diarrhea*

	0	1	2	3	4	5	6	7	8	9	10

0 is Infrequent or absent, 10 is Very frequent or unbearable

Flatulence. (Passing gas)*

	0	1	2	3	4	5	6	7	8	9	10

0 is Infrequent or absent, 10 is Very frequent or unbearable

Burping up food or liquid*

	0	1	2	3	4	5	6	7	8	9	10

0 is Infrequent or absent, 10 is Very frequent or unbearable

Nausea (Vomiting sensation)*

	0	1	2	3	4	5	6	7	8	9	10

0 is Infrequent or absent, 10 is Very frequent or unbearable

Vomiting*

	0	1	2	3	4	5	6	7	8	9	10

0 is Infrequent or absent, 10 is Very frequent or unbearable

Heartburn (Feeling of burning sensation in your chest/upper abdomen) *

	0	1	2	3	4	5	6	7	8	9	10

0 is Infrequent or absent, 10 is Very frequent or unbearable

Feeling of sour or bitter taste in the back of your throat*

	0	1	2	3	4	5	6	7	8	9	10

0 is Infrequent or absent, 10 is Very frequent or unbearable

Loss of appetite*

	0	1	2	3	4	5	6	7	8	9	10

0 is Infrequent or absent, 10 is Very frequent or unbearable

Bleeding with stools and unintended weight loss
Do you have bleeding with stools?*

YesNo
In the last 3-6 months have you lost weight without being on a weight-loss program (Unintended weight loss)?*

YesNo
WARNING!

If you have bleeding with stools and or unintended weight loss, please meet your doctor urgently to rule out potentially serious disease.
Systemic Symptoms

These are common symptoms associated with gut dysfunction that show up outside the gut.

Fatigue*

	0	1	2	3	4	5	6	7	8	9	10

0 is Infrequent or absent, 10 is Very frequent or unbearable

"Brain Fog"*

	0	1	2	3	4	5	6	7	8	9	10

0 is Infrequent or absent, 10 is Very frequent or unbearable

Joint pain/aches and pains*

	0	1	2	3	4	5	6	7	8	9	10

0 is Infrequent or absent, 10 is Very frequent or unbearable

Mood issues like irritability, depression, anger, anxiety*

	0	1	2	3	4	5	6	7	8	9	10

0 is Infrequent or absent, 10 is Very frequent or unbearable

Headaches / Migraines*

	0	1	2	3	4	5	6	7	8	9	10

0 is Infrequent or absent, 10 is Very frequent or unbearable

Poor sleep*

	0	1	2	3	4	5	6	7	8	9	10

0 is Infrequent or absent, 10 is Very frequent or unbearable

Skin rashes*

	0	1	2	3	4	5	6	7	8	9	10

0 is Infrequent or absent, 10 is Very frequent or unbearable

YOUR TOTAL SYMPTOMS SCORE:
Total Symptoms Score*
SYMPTOM SCORING

Less than 60=Mild
61-100=Moderate
101 and more= Severe.
Thank you for filling in this questionnaire. Please feel free to email us at info@drkarmd.com if you need any clarification.
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