GI History & Symptom Review

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Address* This field is required.
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Phone Number* This field is required.
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9
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example@example.com
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Have you ever been diagnosed with a Gastrointestinal Disorder?* This field is required.
Yes
No
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If yes, please list previous diagnosis:
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Have you ever been diagnosed with a Autoimmune Disorder?* This field is required.
Yes
No
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If yes, please list previous diagnosis:
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Have you ever had abdominal surgery?* This field is required.
Yes
No
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If yes, please list the surgery and describe complications (if any):
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Please list any medications or supplements you are taking for your stomach/digestive tract:
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Have you ever completed a food sensitivity test?* This field is required.
Yes
No
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If yes, please describe the results:
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Please answer the following questions to help us identify the best course of action for recovery of your GI function.* This field is required.
Yes
No
Do you consume at least 5 servings of fruits and vegetables per day?
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Do you drink at least 8 glasses of water per day?
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Do you regularly consume soft drinks or fruit juice?
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Do you experience frequent heartburn, burping, gas or bloating during or immediately after meals?
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Have you ever been diagnosed with anemia or any other nutrient deficiency?
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Have you ever been placed on heartburn medication (PPI or H2 blocker)?
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Do you frequently experience indigestion?
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Do you regularly have less than one or more than three bowel movements per day?
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Do you have to take a laxative more than twice a month?
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Are you sensitive to smells or fragrances?
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Do you have regular exposure to exhaust fumes, tobacco smoke, pesticides, commercial chemicals, paint, cleaning chemicals or volatile fumes?
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Have you used antibiotics within the past 2 years?
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Do you experience abdominal bloating, pain, gas, constipation, or diarrhea?
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Have you ever been diagnosed with chronic fatigue syndrome or fibromyalgia?
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Do you experience poor memory, difficulty concentrating, or brain fog?
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Have you ever been diagnosed with depression, anxiety, ADD or ADHD?
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Do you suffer from multiple food sensitivities?
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Do you experience skin issues such as acne, rosacea, or eczema?
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Do you consume at least 5 servings of fruits and vegetables per day?
Do you drink at least 8 glasses of water per day?
Do you regularly consume soft drinks or fruit juice?
Do you experience frequent heartburn, burping, gas or bloating during or immediately after meals?
Have you ever been diagnosed with anemia or any other nutrient deficiency?
Have you ever been placed on heartburn medication (PPI or H2 blocker)?
Do you frequently experience indigestion?
Do you regularly have less than one or more than three bowel movements per day?
Do you have to take a laxative more than twice a month?
Are you sensitive to smells or fragrances?
Do you have regular exposure to exhaust fumes, tobacco smoke, pesticides, commercial chemicals, paint, cleaning chemicals or volatile fumes?
Have you used antibiotics within the past 2 years?
Do you experience abdominal bloating, pain, gas, constipation, or diarrhea?
Have you ever been diagnosed with chronic fatigue syndrome or fibromyalgia?
Do you experience poor memory, difficulty concentrating, or brain fog?
Have you ever been diagnosed with depression, anxiety, ADD or ADHD?
Do you suffer from multiple food sensitivities?
Do you experience skin issues such as acne, rosacea, or eczema?
Yes
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No
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Yes
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No
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Yes
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No
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Yes
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No
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Yes
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No
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Yes
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No
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Yes
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No
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Yes
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No
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Yes
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No
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Yes
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No
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Yes
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No
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Yes
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No
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Yes
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No
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Yes
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No
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Yes
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No
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Yes
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No
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Yes
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No
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Yes
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No
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Please rate each of these symptoms as you have been feeling during the last two weeks. For each question, mark the box that best describes your symptoms. Please do not "over think" these as you answer them. If you do not do certain activities check “not applicable”. Remember, we are asking for YOUR answers. Please rate each of the following 8 questions.* This field is required.
Not at all
Rarely
Sometimes
Often
Always
Not Applicable
Have you had any difficulties carrying out your daily activities?
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Have you had to disrupt your daily activity?
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Have you had any difficulties carrying out your leisure activities?
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Have you had any difficulties focusing, especially when reading or listening to music?
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Have you felt restricted in performing strenuous physical activities like running, lifting, or pushing heavy objects, i.e. pushing a table?
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Has the quality of your work (either at home or on the job) suffered?
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Has it taken you longer to perform certain tasks at work?
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Have you thought that your digestive problems were preventing you from doing your job as you would like to?
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Have you had any difficulties carrying out your daily activities?
Have you had to disrupt your daily activity?
Have you had any difficulties carrying out your leisure activities?
Have you had any difficulties focusing, especially when reading or listening to music?
Have you felt restricted in performing strenuous physical activities like running, lifting, or pushing heavy objects, i.e. pushing a table?
Has the quality of your work (either at home or on the job) suffered?
Has it taken you longer to perform certain tasks at work?
Have you thought that your digestive problems were preventing you from doing your job as you would like to?
Not at all
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Rarely
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Not Applicable
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Not at all
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Please rate each of these symptoms as you have been feeling during the last two weeks. For each question, mark the box that best describes your symptoms. Please do not "over think" these as you answer them. If you do not do certain activities check “not applicable”. Remember, we are asking for YOUR answers. Please rate each of the following 5 questions.* This field is required.
Not at all
Rarely
Sometimes
Often
Always
Not Applicable
Are you afraid that your digestive problems could get worse in the future?
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Do you fear you may get digestive cancer?
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Are you afraid that the medicine that you have been taking for your digestive problems will become less effective as time goes on?
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Have you been worried about not knowing when the next bout of digestive pains or problems would arise?
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Has the slightest worsening of your pains or intestinal activity worried you?
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Are you afraid that your digestive problems could get worse in the future?
Do you fear you may get digestive cancer?
Are you afraid that the medicine that you have been taking for your digestive problems will become less effective as time goes on?
Have you been worried about not knowing when the next bout of digestive pains or problems would arise?
Has the slightest worsening of your pains or intestinal activity worried you?
Not at all
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Rarely
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Not Applicable
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Please rate each of these symptoms as you have been feeling during the last two weeks. For each question, mark the box that best describes your symptoms. Please do not "over think" these as you answer them. If you do not do certain activities check “not applicable”. Remember, we are asking for YOUR answers. Please rate each of the following 6 questions.* This field is required.
Not at all
Rarely
Sometimes
Often
Always
Not Applicable
Are you concerned that a change in diet on weekends or while on vacation could trigger your digestive problems?
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Do you think you are more sensitive to certain foods than other people?
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Have you felt frustrated about not being able to eat like everyone else?
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Have you been careful about what you eat or drink?
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Have you felt it necessary to follow a strict diet?
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Has it been hard for you to eat in a restaurant or at someone's home?
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Are you concerned that a change in diet on weekends or while on vacation could trigger your digestive problems?
Do you think you are more sensitive to certain foods than other people?
Have you felt frustrated about not being able to eat like everyone else?
Have you been careful about what you eat or drink?
Have you felt it necessary to follow a strict diet?
Has it been hard for you to eat in a restaurant or at someone's home?
Not at all
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Rarely
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Not Applicable
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Please rate each of these symptoms as you have been feeling during the last two weeks. For each question, mark the box that best describes your symptoms. Please do not "over think" these as you answer them. If you do not do certain activities check “not applicable”. Remember, we are asking for YOUR answers. Please rate each of the following 3 questions.* This field is required.
Not at all
Rarely
Sometimes
Often
Always
Not Applicable
Have your digestive problems impacted your ability to fall asleep?
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Have you been awakened at night because of digestive problems?
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Have your digestive problems kept you awake for most of the night?
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Have your digestive problems impacted your ability to fall asleep?
Have you been awakened at night because of digestive problems?
Have your digestive problems kept you awake for most of the night?
Not at all
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Rarely
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Sometimes
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Often
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Please rate each of these symptoms as you have been feeling during the last two weeks. For each question, mark the box that best describes your symptoms. Please do not "over think" these as you answer them. If you do not do certain activities check “not applicable”. Remember, we are asking for YOUR answers. Please rate each of the following 9 questions.* This field is required.
Not at all
Rarely
Sometimes
Often
Always
Not Applicable
When you are invited to someone's home or when going out, are you concerned with having flatulence (gas), belching, a rumbling stomach, or an urgent need to have a bowel movement...?
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Have you been bothered by flatulence (gas)?
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Have you been bothered by your stomach rumbling?
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Have you been bothered by a bloated stomach?
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Has it been difficult for you to have a bowel movement when not at home?
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Have you had to undo your button, loosen your belt or even lie down after meals?
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Have you avoided wearing tight clothes?
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Have you been satisfied with your intestinal activity?
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Have you been satisfied with your digestion?
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When you are invited to someone's home or when going out, are you concerned with having flatulence (gas), belching, a rumbling stomach, or an urgent need to have a bowel movement...?
Have you been bothered by flatulence (gas)?
Have you been bothered by your stomach rumbling?
Have you been bothered by a bloated stomach?
Has it been difficult for you to have a bowel movement when not at home?
Have you had to undo your button, loosen your belt or even lie down after meals?
Have you avoided wearing tight clothes?
Have you been satisfied with your intestinal activity?
Have you been satisfied with your digestion?
Not at all
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Rarely
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Often
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Please rate each of the statements as you have been feeling during the last two weeks. For each statement, mark the box that best describes how you feel. Please do not "over think" these as you answer them. Remember, we are asking for YOUR answers. Please rate each of the following 6 statement.* This field is required.
Totally Disagree
Mostly Disagree
Don't Know
Mostly Agree
Totally Agree
I feel that my health is more delicate than other people's.
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I consider my health to be excellent.<br>
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I will have a hearty meal with friends or at family gatherings even if it will make my digestive problems worse.
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Despite my digestive problems, I think that over the next few years, I will be able to achieve the things that matter to me.
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I attach little importance to my digestive pains, even if they bother me in everyday activities.
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Despite my digestive problems I can lead a normal life.
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
I feel that my health is more delicate than other people's.
I consider my health to be excellent.<br>
I will have a hearty meal with friends or at family gatherings even if it will make my digestive problems worse.
Despite my digestive problems, I think that over the next few years, I will be able to achieve the things that matter to me.
I attach little importance to my digestive pains, even if they bother me in everyday activities.
Despite my digestive problems I can lead a normal life.
Totally Disagree
Row 0, Column 0
Mostly Disagree
Row 0, Column 1
Don't Know
Row 0, Column 2
Mostly Agree
Row 0, Column 3
Totally Agree
Row 0, Column 4
Totally Disagree
Row 1, Column 0
Mostly Disagree
Row 1, Column 1
Don't Know
Row 1, Column 2
Mostly Agree
Row 1, Column 3
Totally Agree
Row 1, Column 4
Totally Disagree
Row 2, Column 0
Mostly Disagree
Row 2, Column 1
Don't Know
Row 2, Column 2
Mostly Agree
Row 2, Column 3
Totally Agree
Row 2, Column 4
Totally Disagree
Row 3, Column 0
Mostly Disagree
Row 3, Column 1
Don't Know
Row 3, Column 2
Mostly Agree
Row 3, Column 3
Totally Agree
Row 3, Column 4
Totally Disagree
Row 4, Column 0
Mostly Disagree
Row 4, Column 1
Don't Know
Row 4, Column 2
Mostly Agree
Row 4, Column 3
Totally Agree
Row 4, Column 4
Totally Disagree
Row 5, Column 0
Mostly Disagree
Row 5, Column 1
Don't Know
Row 5, Column 2
Mostly Agree
Row 5, Column 3
Totally Agree
Row 5, Column 4
1 of 6
26
Please rate each of the statements as you have been feeling during the last two weeks. For each statement, mark the box that best describes how you feel. Please do not "over think" these as you answer them. Remember, we are asking for YOUR answers. Please rate each of the following 3 statement.* This field is required.
Totally Disagree
Mostly Disagree
Don't Know
Mostly Agree
Totally Agree
I feel that there is nothing I can do to change my digestive problems.
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
I feel that I am not in control of my digestive problems.<br>
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
I have no idea what I should do when I have my digestive problems.
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
I feel that there is nothing I can do to change my digestive problems.
I feel that I am not in control of my digestive problems.<br>
I have no idea what I should do when I have my digestive problems.
Totally Disagree
Row 0, Column 0
Mostly Disagree
Row 0, Column 1
Don't Know
Row 0, Column 2
Mostly Agree
Row 0, Column 3
Totally Agree
Row 0, Column 4
Totally Disagree
Row 1, Column 0
Mostly Disagree
Row 1, Column 1
Don't Know
Row 1, Column 2
Mostly Agree
Row 1, Column 3
Totally Agree
Row 1, Column 4
Totally Disagree
Row 2, Column 0
Mostly Disagree
Row 2, Column 1
Don't Know
Row 2, Column 2
Mostly Agree
Row 2, Column 3
Totally Agree
Row 2, Column 4
1 of 3
27
Please rate each of the statements as you have been feeling during the last two weeks. For each statement, mark the box that best describes how you feel. Please do not "over think" these as you answer them. Remember, we are asking for YOUR answers. Please rate each of the following 3 statement.* This field is required.
Totally Disagree
Mostly Disagree
Don't Know
Mostly Agree
Totally Agree
I believe that any stress causes my digestive problems.
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Major aggravation trigger my digestive problems.
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Even the least bit of aggravation triggers my digestive problems.
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
I believe that any stress causes my digestive problems.
Major aggravation trigger my digestive problems.
Even the least bit of aggravation triggers my digestive problems.
Totally Disagree
Row 0, Column 0
Mostly Disagree
Row 0, Column 1
Don't Know
Row 0, Column 2
Mostly Agree
Row 0, Column 3
Totally Agree
Row 0, Column 4
Totally Disagree
Row 1, Column 0
Mostly Disagree
Row 1, Column 1
Don't Know
Row 1, Column 2
Mostly Agree
Row 1, Column 3
Totally Agree
Row 1, Column 4
Totally Disagree
Row 2, Column 0
Mostly Disagree
Row 2, Column 1
Don't Know
Row 2, Column 2
Mostly Agree
Row 2, Column 3
Totally Agree
Row 2, Column 4
1 of 3
28
Section A. Please rate each of these symptoms as you have been feeling during the last four months. For each question, mark the box that best describes your symptoms: None/Rarely– You have never experience the symptom or the symptom is familiar to you but you feel it is insignificant; Occasionally – Symptom comes and goes and is linked in your mind to stress, diet, fatigue or some identifiable trigger; Often – Symptom occurs 2-3 times per week and/or with a frequency that bothers you enough that you would like to do something about it; Frequently – Symptom occurs 4 or more times per week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis. Please do not "over think" these as you answer them. Remember, we are asking for YOUR answers. Please rate each of the following 7 medical conditions.* This field is required.
None/Rarely
Occasionally
Often
Frequently
Indigestion
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Excessive burping, belching, and/or bloating following meals
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Stomach spasms and cramping during or after eating
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
A sensation that food just sits in your stomach creating uncomfortable fullness, pressure and bloating during or after a meal
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Bad taste in your mouth
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Small amounts of food fill you up immediately
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Skip meals or eat erratically because you have no appetite
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Indigestion
Excessive burping, belching, and/or bloating following meals
Stomach spasms and cramping during or after eating
A sensation that food just sits in your stomach creating uncomfortable fullness, pressure and bloating during or after a meal
Bad taste in your mouth
Small amounts of food fill you up immediately
Skip meals or eat erratically because you have no appetite
None/Rarely
Row 0, Column 0
Occasionally
Row 0, Column 1
Often
Row 0, Column 2
Frequently
Row 0, Column 3
None/Rarely
Row 1, Column 0
Occasionally
Row 1, Column 1
Often
Row 1, Column 2
Frequently
Row 1, Column 3
None/Rarely
Row 2, Column 0
Occasionally
Row 2, Column 1
Often
Row 2, Column 2
Frequently
Row 2, Column 3
None/Rarely
Row 3, Column 0
Occasionally
Row 3, Column 1
Often
Row 3, Column 2
Frequently
Row 3, Column 3
None/Rarely
Row 4, Column 0
Occasionally
Row 4, Column 1
Often
Row 4, Column 2
Frequently
Row 4, Column 3
None/Rarely
Row 5, Column 0
Occasionally
Row 5, Column 1
Often
Row 5, Column 2
Frequently
Row 5, Column 3
None/Rarely
Row 6, Column 0
Occasionally
Row 6, Column 1
Often
Row 6, Column 2
Frequently
Row 6, Column 3
1 of 7
29
Section B. Please rate each of these symptoms as you have been feeling during the last four months. For each question, mark the box that best describes your symptoms: None/Rarely– You have never experience the symptom or the symptom is familiar to you but you feel it is insignificant; Occasionally – Symptom comes and goes and is linked in your mind to stress, diet, fatigue or some identifiable trigger; Often – Symptom occurs 2-3 times per week and/or with a frequency that bothers you enough that you would like to do something about it; Frequently – Symptom occurs 4 or more times per week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis. Please do not "over think" these as you answer them. Remember, we are asking for YOUR answers. Please rate each of the following 9 medical conditions.* This field is required.
None/Rarely
Occasionally
Often
Frequently
Strong emotions, or the thought or smell of food aggravates your stomach or make it hurt
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Feel hungry an hour or two after eating a good-sized meal
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Stomach pain, burning and/or aching over a period of 1-4 hours after eating
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Stomach pain, burning and/or aching relieved by eating food; drinking carbonated beverages, cream or milk, or taking antacids
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Burning sensation in the lower part of your chest, especially when lying down or bending forward
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Digestive problems that subside with rest and relaxation
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Eating spicy and fatty (fried) foods, chocolate, coffee, alcohol, citrus or hot peppers causes your stomach to burn or ache
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Feel a sense of nausea when you eat
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Difficulty or pain when swallowing food or beverage
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Strong emotions, or the thought or smell of food aggravates your stomach or make it hurt
Feel hungry an hour or two after eating a good-sized meal
Stomach pain, burning and/or aching over a period of 1-4 hours after eating
Stomach pain, burning and/or aching relieved by eating food; drinking carbonated beverages, cream or milk, or taking antacids
Burning sensation in the lower part of your chest, especially when lying down or bending forward
Digestive problems that subside with rest and relaxation
Eating spicy and fatty (fried) foods, chocolate, coffee, alcohol, citrus or hot peppers causes your stomach to burn or ache
Feel a sense of nausea when you eat
Difficulty or pain when swallowing food or beverage
None/Rarely
Row 0, Column 0
Occasionally
Row 0, Column 1
Often
Row 0, Column 2
Frequently
Row 0, Column 3
None/Rarely
Row 1, Column 0
Occasionally
Row 1, Column 1
Often
Row 1, Column 2
Frequently
Row 1, Column 3
None/Rarely
Row 2, Column 0
Occasionally
Row 2, Column 1
Often
Row 2, Column 2
Frequently
Row 2, Column 3
None/Rarely
Row 3, Column 0
Occasionally
Row 3, Column 1
Often
Row 3, Column 2
Frequently
Row 3, Column 3
None/Rarely
Row 4, Column 0
Occasionally
Row 4, Column 1
Often
Row 4, Column 2
Frequently
Row 4, Column 3
None/Rarely
Row 5, Column 0
Occasionally
Row 5, Column 1
Often
Row 5, Column 2
Frequently
Row 5, Column 3
None/Rarely
Row 6, Column 0
Occasionally
Row 6, Column 1
Often
Row 6, Column 2
Frequently
Row 6, Column 3
None/Rarely
Row 7, Column 0
Occasionally
Row 7, Column 1
Often
Row 7, Column 2
Frequently
Row 7, Column 3
None/Rarely
Row 8, Column 0
Occasionally
Row 8, Column 1
Often
Row 8, Column 2
Frequently
Row 8, Column 3
1 of 9
30
Section C. Please rate each of these symptoms as you have been feeling during the last four months. For each question, mark the box that best describes your symptoms: None/Rarely– You have never experience the symptom or the symptom is familiar to you but you feel it is insignificant; Occasionally – Symptom comes and goes and is linked in your mind to stress, diet, fatigue or some identifiable trigger; Often – Symptom occurs 2-3 times per week and/or with a frequency that bothers you enough that you would like to do something about it; Frequently – Symptom occurs 4 or more times per week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis. Please do not "over think" these as you answer them. Remember, we are asking for YOUR answers. Please rate each of the following 10 medical conditions.* This field is required.
None/Rarely
Occasionally
Often
Frequently
When massaging under your rib cage on your left side, there is pain, tenderness or soreness
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Indigestion, fullness or tension in your abdomen is delayed, occurring 2-4 hours after eating a meal
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Lower abdominal discomfort is relieved with the passage of gas or with a bowel movement
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Specific foods/beverages aggravate indigestion
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
The consistency or form of your stool changes (e.g., from narrow to loose) within the course of a day
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Stool odor is embarrassing
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Undigested food in your stool
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Three or more large bowel movements daily
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Diarrhea (frequent loose, water stool)
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Bowel movement shortly after eating (within 1 hour)
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
When massaging under your rib cage on your left side, there is pain, tenderness or soreness
Indigestion, fullness or tension in your abdomen is delayed, occurring 2-4 hours after eating a meal
Lower abdominal discomfort is relieved with the passage of gas or with a bowel movement
Specific foods/beverages aggravate indigestion
The consistency or form of your stool changes (e.g., from narrow to loose) within the course of a day
Stool odor is embarrassing
Undigested food in your stool
Three or more large bowel movements daily
Diarrhea (frequent loose, water stool)
Bowel movement shortly after eating (within 1 hour)
None/Rarely
Row 0, Column 0
Occasionally
Row 0, Column 1
Often
Row 0, Column 2
Frequently
Row 0, Column 3
None/Rarely
Row 1, Column 0
Occasionally
Row 1, Column 1
Often
Row 1, Column 2
Frequently
Row 1, Column 3
None/Rarely
Row 2, Column 0
Occasionally
Row 2, Column 1
Often
Row 2, Column 2
Frequently
Row 2, Column 3
None/Rarely
Row 3, Column 0
Occasionally
Row 3, Column 1
Often
Row 3, Column 2
Frequently
Row 3, Column 3
None/Rarely
Row 4, Column 0
Occasionally
Row 4, Column 1
Often
Row 4, Column 2
Frequently
Row 4, Column 3
None/Rarely
Row 5, Column 0
Occasionally
Row 5, Column 1
Often
Row 5, Column 2
Frequently
Row 5, Column 3
None/Rarely
Row 6, Column 0
Occasionally
Row 6, Column 1
Often
Row 6, Column 2
Frequently
Row 6, Column 3
None/Rarely
Row 7, Column 0
Occasionally
Row 7, Column 1
Often
Row 7, Column 2
Frequently
Row 7, Column 3
None/Rarely
Row 8, Column 0
Occasionally
Row 8, Column 1
Often
Row 8, Column 2
Frequently
Row 8, Column 3
None/Rarely
Row 9, Column 0
Occasionally
Row 9, Column 1
Often
Row 9, Column 2
Frequently
Row 9, Column 3
1 of 10
31
Section D. Please rate each of these symptoms as you have been feeling during the last four months. For each question, mark the box that best describes your symptoms: None/Rarely– You have never experience the symptom or the symptom is familiar to you but you feel it is insignificant; Occasionally – Symptom comes and goes and is linked in your mind to stress, diet, fatigue or some identifiable trigger; Often – Symptom occurs 2-3 times per week and/or with a frequency that bothers you enough that you would like to do something about it; Frequently – Symptom occurs 4 or more times per week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis. Please do not "over think" these as you answer them. Remember, we are asking for YOUR answers. Please rate each of the following 10 medical conditions.* This field is required.
None/Rarely
Occasionally
Often
Frequently
Discomfort, pain or cramps in your colon (lower abdominal area)
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Emotional stress and/or eating raw fruits and vegetables causes abdominal bloating, pain, cramps, or gas
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Generally constipated (or straining during bowel movements)
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Stool is small, hard and dry
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Pass mucus in your stool
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Pass blood in your stool
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Alternate between constipation and diarrhea
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Rectal pain, itching or cramping
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
No urge to have a bowel movement
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
An almost continual need to have a bowel movement
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Discomfort, pain or cramps in your colon (lower abdominal area)
Emotional stress and/or eating raw fruits and vegetables causes abdominal bloating, pain, cramps, or gas
Generally constipated (or straining during bowel movements)
Stool is small, hard and dry
Pass mucus in your stool
Pass blood in your stool
Alternate between constipation and diarrhea
Rectal pain, itching or cramping
No urge to have a bowel movement
An almost continual need to have a bowel movement
None/Rarely
Row 0, Column 0
Occasionally
Row 0, Column 1
Often
Row 0, Column 2
Frequently
Row 0, Column 3
None/Rarely
Row 1, Column 0
Occasionally
Row 1, Column 1
Often
Row 1, Column 2
Frequently
Row 1, Column 3
None/Rarely
Row 2, Column 0
Occasionally
Row 2, Column 1
Often
Row 2, Column 2
Frequently
Row 2, Column 3
None/Rarely
Row 3, Column 0
Occasionally
Row 3, Column 1
Often
Row 3, Column 2
Frequently
Row 3, Column 3
None/Rarely
Row 4, Column 0
Occasionally
Row 4, Column 1
Often
Row 4, Column 2
Frequently
Row 4, Column 3
None/Rarely
Row 5, Column 0
Occasionally
Row 5, Column 1
Often
Row 5, Column 2
Frequently
Row 5, Column 3
None/Rarely
Row 6, Column 0
Occasionally
Row 6, Column 1
Often
Row 6, Column 2
Frequently
Row 6, Column 3
None/Rarely
Row 7, Column 0
Occasionally
Row 7, Column 1
Often
Row 7, Column 2
Frequently
Row 7, Column 3
None/Rarely
Row 8, Column 0
Occasionally
Row 8, Column 1
Often
Row 8, Column 2
Frequently
Row 8, Column 3
None/Rarely
Row 9, Column 0
Occasionally
Row 9, Column 1
Often
Row 9, Column 2
Frequently
Row 9, Column 3
1 of 10
32
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