Digestive Intake Form

Dr . Rinde's Digestive Intake Form

General Digestive Health questions. Dr. Rinde will respond to you personally. This is not a diagnostic tool but is used as a screening instrument.
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Email*
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Full Name*

First NameLast Name
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState

Zip Code
What state do you Reside in?*
Would You Like Dr. Rinde to contact you with comments on this form?

YesNoNot Applicable
Please Describe The Typical Appearance of Your Stool

Type 1: Separate hard lumps, like nuts (hard to pass)Type 2: Sausage-shaped, but lumpyType 3: Like a sausage but with cracks on its surfaceType 4: Like a sausage or snake, smooth and softType 5: Soft blobs with clear cut edges (passed easily)Type 6: Fluffy pieces with ragged edges, a mushy stoolType 7: Watery, no solid pieces. Entirely liquid

Section A Click on the section that describes your symptoms

	almost never (0)	sometimes (mild)-1	often (moderate)-2	most of the time (severe)-3
stomach upset after eating
bloating in stomach after eating
burning or belching
feeling of undigested food in stomach
uncomfortable fullness in stomach
known or suspected food intolerances
fullness after small amounts of food

Section B Click on the section that describes your symptoms

	Almost Never(0)	Sometimes (1)	Often (2)	Most of the time (3)
Burning or gnawing stomach pain
Heartburn of ingestion
pain relieved by antacids
stomach pain from stress or spicy foods
waking at night with stomach pain
pain temporarily improved by eating food or drinking milk
History of ulcer,gastritis, or antacid usage
naseua or vomitting after eating
use of aspirin or anti-inflammatory drugs

Section C: Click on the section that describes your symptoms

	almost never (0)	Sometimes (1)	Often (2)	Most of the time (3)
Bloating 1-3 hours or more after eating
Bloating in lower abdomen
foul-smelling stools or gas
shiny or loose, floating stools
abdominal cramping or pain
Diarrhea or poorly formed stools
known or suspected food allergies, sensitivities, or intolerances
difficulty gaining weight
undigested food or mucus in stools

Section D Click on the section that describes your symptoms

	almost never (0)	Sometimes (1)	Often (2)	Most of the time (3)
constipation and/or diarrhea
abdominal pain or bloating
mucus or blood in stool
joint pain, swelling, or arthritis
chronic fatigue or tiredness
known or suspected food allergies, sensitivities, or intolerances
sinus or nasal congestion
chronic or frequent inflammations
eczema, skin rashes, or hives
asthma, hayfever, or airborne allergies
confusion, poor memory, or mood swings
use of aspirin or anti-inflammatory drugs
history of antibiotic or corticosteriod use
alcohol use

Section E Click on the section that describes your symptoms

	almost never (0)	Sometimes (1)	Often (2)	Most of the time (3)
Dislike or cant tolerate fatty food
headaches after eating
light colored stool
constipation
hard stool
oily skin
acne
pain and tenderness under right side of rib
elevated cholesterol or triglycerides
hemorrhoids
Bleeding during or after bowel movements

Feel freee to add additional comments here
Dietary Questions pertaining to digestive health
Which of the following do you have any known or suspected sensitivities to.

GlutenMilkCornSoyEggsNightshadesOther (please explain)
Feel freee to add additional comments here
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Dr . Rinde's Digestive Intake Form