SIBO Freedom Intake Form

SIBO Freedom Application Form
Name*
Why would you like to join SIBO Freedom?*
What part of your health (physical or emotional) are you struggling with most right now?*
How much does this affect your life on a day to day basis?*
1=low, 10= high
Could you describe how it impacts your life for me?*
(i.e. what does it stop you from doing?)
What have you tried so far? And how effective or not have your past treatments been?*
Do you currently have SIBO?*
(if yes, please email a copy of your test results to admin@kirsten-greene.com)
How much do you understand about what's going on with your body and what's causing your digestive symptoms?*
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Height*
Weight*
Address*
Phone number*
Email*
Instagram name*
Would you like to receive newsletters from me*

Yes pleaseNo thanksAlready get them!
Profession*
Relationship Status*

SinglePartnerMarriedDivorced
Children? If yes, how many and what age*
For female clients: Are you pregnant, breastfeeding or planning to have babies?*

Yes, I'm pregnantNoI might be pregnantI'm trying to get pregnantI'm currently breastfeeding
GP*
Name, Clinic & Phone Number
How did you "find" me?*
How many doctors, naturopaths or medical professionals have you seen to try and get better?*
Have you consulted with a Natural Medicine Practitioner in the past?*

YesNo
If yes please provide details of when and why*
When did you first become aware of your symptoms*
On a scale of 1 - 10 how happy are you with your health right now?*
1 = low, 10 = high
On a scale of 1-10 how motivated are you in your work/personal life?*
1 = low, 10 = high
On a scale of 1 -10 how stressed do you feel right now?*
1 = low, 10 = high
What are your key stressors?*
If anything was possible what would you wish for?*
What is most important to you and why?*
What are the things that make you happy?*
List 5 things that you feel you are ‘putting up with’ right now?*
What are the 3 biggest changes you want to make in your life over the next year?*
What would you like to achieve in our time working together?*
What approaches motivate /demotivate you?*
What would you like me to do if you struggle with your goals?*
What are your top 3 reasons for wanting to participate in SIBO Freedom?*
Reason 2*
Reason 3*
What was your final 'this is it' moment that triggered you to go ahead and join SIBO Freedom? *
What was stopping you from joining before? *
Barriers, concerns etc
Please list any pharmaceutical medications you are currently taking*
Name of medication | Reason for taking | Dosage and strength
Please list any herbal or nutritional supplements you are currently taking *
Name of supplement | Reason for taking | Dosage and strength. Important: Please include brand name so I can check it out.
Details of any past major illnesses, surgeries, injuries, immunisations*
How would you describe your appetite*
Love my food Picker & grazer Three meals a day Eat on the run Often forget to eat Always thinking about food
What best describes your style of eating (Check all that apply)*

Love my foodPicker & grazerThree meals a dayEat on the runOften forget to eatAlways thinking about food
Food Allergies & Intolerances (Check all that apply)*

GlutenGrainsDairy (lactose)NutsShellfishOther
Which of the following do you consume*

WaterCoffeeSoft DrinksAlcoholDairyJuiceAdded SugarArticial SweetenersCigarettesRecreationals
What exercise do you do?*
How would you rate your physical energy levels on a scale of 1 - 10?*
(1 = low, 10 = high)
How many times a week do you exercise?*
How many hours of work per week do you average?*
Number of hours
How would you rate your anxiety levels on a scale of 1 - 10?*
1 = zen monk, 10 you're constantly on the verge of a meltdown and/or are having panic attacks
Life events: Have any of these occurred recently (check all that apply)*

Changed jobsMoved houseSeparated or divorcedLoss of a loved oneWorked over 50 hours in a weekTravelled overseasOtherNone
Upper Gastrointestinal System (check all that apply)*

Belching or gas within an hour of eatingHeartburn or acid reuxBloating within 1-2 hours after eatingStomach pains or crampsBad breathNever feel like eating breakfastFeel better if you do not eatTired after eatingNever satisfied after eating3pm slump cravingsOvereating in the eveningsOtherNone
Bloating Scale 1 - 10*
(1 being low, 10 being high)
Can you describe your bloating for me?*
(ie, timing of, location, pain / no pain)
How many times per week do you have a bowel motion?*
Number of times per week
Lower Gastrointestinal System (Check all that apply)*

Food allergies or intolerancesAbdominal bloatingPulse speeds after eatingSinus congestionCrave breadDiarrhoeaConstipationAlternating diarrhoea and constipationLess than one bowel movement per dayMore than three bowel movements a dayUndigested food in stoolsMucous in stoolBlood in stoolItchy AnusCoating on tongueFungus or yeast infections (i.e. Candida)Excessive foul smelling gasCramping in lower abdominal regionOtherNone
Cardiovascular System (Check all that apply)*

Aware of heavy and/or irregular breathingCough at nightBlush easilyDull pain or tightness in chestMuscle cramps with exertionSwollen ankles, especially at the end of the dayFrequent sighingShortness of breath with moderate exertionOtherNone
Urinary System (check all that apply)*

Pain in mid back regionPuffy around the eyesDark circles under eyesHistory of kidney stonesCloudy, bloody, or darkened urineStrong urine odourNoneOther
Liver & Gall Bladder (check all that apply)*

Stomach upset by greasy foodsNauseaHeadache over eyesGallbladder removedCan't handle alcoholHistory of morning sicknessDry, flaky skin or hairSensitive to chemicalsPain under right side of ribcageHaemorrhoids or varicose veinsChronic fatigue or FibromyalgiaBitter taste in mouth, especially after mealsYellowish skinOtherNone
Possible Mineral Deficiencies (check all that apply)*

Bone loss (reduced bone density on scan)Calf, foot or toe cramps on restCold soresFrequent skin rashes or hivesJoints pop or clickExcessively exible jointsDecreased sense of taste or smellMorning sicknessChocolate cravingsSugar cravingsSalty cravingsHistory of anaemiaWhite spots on fingernailsCuts heal slowly and/or scar easilyHerniated discHistory of bone spursTeeth grinding at nightOtherNone
Possible Vitamin Deficiencies (check all that apply)*

Muscles become easily fatiguedVulnerable to insect bitesNumbness, tingling or itching in hands and feetDepressedAnxious, a worrier, apprehensiveNervous or agitatedWhole body or limb can jerk as falling asleepNight sweatsRestless leg syndromeCracks at corners of mouthFragile skinSmall bumps on backs of armsNose bleedsTendency to bruise easilyBleeding gumsOtherNone
Immune System*

Runny or drippy noseCatch colds at beginning of winterMucous producing coughFrequent colds or fluAcne (adult)Itchy skinCysts, boils or rashesHistory of: Epstein Barr, Mono, Herpes, Chronic Fatigue SyndromeOtherNone
How many times per year do you get a cold or flu?*
Number of times per year
Adrenal System*

Tend to be "night owl"Tired when you wake, awake when you're tiredOften on edgeBlood pressure 120/80Headache after exercisingFeel wired or jittery after drinking coffeeClench or grind teethCalm on the outside, troubled on the insideLow back pain, worse with fatigueDizziness if you stand up quicklyCrave salty foodsPerspire easilyChronic fatigueAfternoon yawningAfternoon headacheOtherNone
How is your sleep?*
(ie, interrupted, sleep through, restful, non-restful, nightmares, no dreams etc...)
HPA Axis*

Flush easilyFast pulse at restIntolerance to high temperaturesDislike of coldDifficult, infrequent bowel movementsDryness of skinThick, brittle nailsOuter third of eyebrow thinsPuffy hands and feetSwollen upper eyelidsWeak musclesSlow mental processes, forgetfulnessSlow heart beatsLoss of appetiteAbdominal swellingLack of sexual interestInfertilitySwelling of the neckThinning hair on scalp, face or genitalsOtherNone
For Women*

Depression during periodsPMSCrave chocolate around periodsBreast tenderness associated with cycleExcessive menstrual flowOccasional skipped periodScanty blood flow during periodsNo menstruationIrregular cycleEndometriosisUterine fibroidsThrushBreast fibroidsPolycystic Ovarian SyndromePainful intercourseVaginal dischargeVaginal drynessVaginal itchinessGain weight around hips and thighsExcess facial or body hairNight sweatsHot flushesThinning skinDecreased sexual interestOtherNone
For Men*

Prostrate issuesDifficulty with urinationDifficult to start and stop urine streamPain or burning with urinationWaking to urinate at nightDecreased sexual functionDecreased sexual interestOtherNone
Family History*
Anything you feel is significant
You got to the end! Awesome. Thanks so much. Have all the questions brought any more things to mind? Can you detail your biggest internal struggles in your words for me, how are you feeling INSIDE about all this...?*
The more I know. The more I can help. x x x
Anything else I have not asked and you would like me to know?*
I have read and agree to the T&C's as stated on the Kirsten Greene ND website.*

Yes
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