GI Questionnaire

The health of your gut can impact every function of your body. If you are unable to digest and absorb nutrients effectively your health can be profoundly impacted. We have started offering the GI Map to our patients. It has truly been lifechanging for some of them once their gut issues were recognized and addressed.

Name *

First

Last

Email *

Phone

What is your height?

What is your weight?

What supplements are you taking?

Have you been told that you have Irritable Bowel Syndrome?

• Yes
• No

Please check if you currently have these symptoms

• Belching or gas
• Heartburn or reflux
• Bad breath
• Bloating
• Stool that is loose and unformed
• Less than 1 BM a day
• Hard stools
• Abdominal pain after eating certain foods
• Undigested food in stool
• Nausea or vomiting
• Stool that is light in color
• Fatigue
• Brain fog
• Anxiety
• Skin problems
• Body aches and pains

How long have you had these symptoms?

Have you been on antibiotics in the past year?

• Yes
• No

Is there anything you have tried that has made your symptoms better?

Are there foods that seem to bother your stomach? If yes, list them.

Please list medications that you are taking

Is your stress level high?

• Yes
• No

Do you have activities you engage in to relieve stress?

• Yes
• No

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