Digestive Health Questionnaire

Thank you for completing this information so that your practitioner can learn more about your digestive health.

Digestive Health Overview

How would you rate your current digestive health? (1 = Worst, 5 = Best) * Required

1 2 3 4 5

Please share more about why you chose this rating: Optional

Are there any foods that you avoid because of how they make you feel? If yes, please name the food and symptom: Optional

Are there foods that you crave? If so, please explain: Optional

Do you have symptoms immediately after eating (e.g. bloating, gas, sneezing, hives)? Please explain: Optional

Are you aware of any delayed symptoms after eating (e.g. fatigue, muscle aches, sinus congestion)? Please explain: Optional

Have you had periods of eating junk food, binge eating, or dieting? List diets you have been on significantly: Optional

What percentage of your meals are home-cooked? Please describe: Optional

Do you experience health concerns that you attribute to your digestive system? If yes, please explain: Optional

Describe your diet at the onset of the health concerns listed above: Optional

How often did you take antibiotics in infancy/childhood? Optional

How often have you taken antibiotics as a teen? Optional

How often have you taken antibiotics as an adult? Optional

Do you have any known food allergies or sensitivities? Optional

Which of the following foods do you consume regularly? Optional

SodaFast foodDiet sodaGluten (wheat, rye, barley)Refined sugarDairy (milk, cheese, yogurt)AlcoholCoffee

Are you currently on a special diet? Optional

Autoimmune Paleo (AIP)PaleoKetogenicBlood type dietDairy restricted or dairy-freeRaw foodVegetarianRefined sugar-freeVeganGluten-freeOther (please describe below)

If you checked 'other' for special diets, please describe in detail: Optional

List all vitamins, minerals, herbs and nutritional supplements you are currently taking: Optional

Bowel Movements & Gastrointestinal Status

Bowel Movement Frequency * Required

1–3 times per dayMore than 3 times per dayEvery other dayOnce every 3 daysLess than once every 3 daysNot regularly every dayJust a few times per week

Bowel Movement Consistency * Required

Soft & well formedOften floatDifficult to passDiarrheaThin, long or narrowSmall and hardLoose but not wateryAlternating between hard and loose

Bowel Movement Color * Required

Medium brownVery dark or blackGreenishBlood is visibleVariableYellow, light brownChalky coloredGreasy, shiny

Do you ever experience painful bowel movements? If yes, how often? Optional

Do you experience intestinal gas? Please explain if it is excessive, occasional, odorous, etc: Optional

If experiencing excessive gas, are there foods you consume that could be related? Optional

Food Poisoning History (Detail when/where, treatments, and if fully recovered): Optional

Have you been exposed to chemicals or toxic metals (lead, mercury, arsenic, aluminum)? Optional

Lifestyle & Wellness Factors

Do you engage in regular exercise and/or movement? (Describe types and frequency): Optional

How do you handle stress? Optional

Do you sleep between 6 and 8 hours per night? * Required

Yes No

Are you satisfied with the quality of your sleep? * Required

Yes No

How are your moods in general? Do you experience anxiety, depression, or anger? Optional

Describe your usual level of energy (1 = Worst, 5 = Best): * Required

1 2 3 4 5

Do you have health goals related to improving your digestive health? Please share: Optional

Is there anything else your practitioner should know about your diet or relationship to food? Optional

Digestive Health Questionnaire

Preview