SIBO Form

1

Do you experience any of the following?Select all that apply

Bloating

Chronic diarrhoea or loose stools (either continuous or intermittent)

Chronic constipation or incomplete bowel movements

Abdominal cramping or pain

Frequent belching or flatulence

None of the above

2

Have you previously had a diagnosis of SIBO?

YESNO

3

Do you have bloating that gets worse throughout the day and/or after eating?

YESNO

4

Do you rely on medication (Movicol, lactulose etc.) to maintain regular bowel movements?

YESNO

5

Are you currently taking a Proton Pump Inhibitor (Nexium, Omeprazole, Esomeprazole) or have in the past?

YESNO

6

Have you had an episode of food poisoning and your gut has never been the same since?

YESNO

7

Have you had any abdominal surgery e.g laparoscopy,weight loss surgery, c-section?

YESNO

8

Do your digestive symptoms get worse after fibre and/or prebiotics such as inulin, flax, psyllium husk, etc.?*

YESNO

9

Do you have low iron and/or B12 that cannot be explained by another cause (e.g. heavy menstrual bleeding, vegan diet, medication)?

YESNO

10

Do you experience restless legs (or the sensation to need to move the legs) at night?

YESNO

11

Have you been diagnosed with any of the following conditionsSelect all that apply

Hashimoto’s Thyroiditis

Crohn’s or Ulcerative Colitis

Scleroderma

Diabetes

Fibromyalgia or Chronic Fatigue

Rosacea

IBS

None of the above

12

Do you experience pain, tenderness, soreness on left side under rib cage?

YESNO

13

Do your symptoms improve with rest, relaxation or on holidays?

YESNO

14

Do you experience reflux, acid indigestion, frequent sore throats or morning time hoarseness?

YESNO

15

Total

16

What is your name?

First Name

Last Name

17

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