Scooby Health GI & Digestive Lifestyle Questionnaire

  • Gastrointestinal & Digestive Lifestyle Questionnaire

  • Today's Date*
     - -
  • Date of Birth*
     - -

  • Part 1

    This section is aimed at assessing lifestyle and gastrointestinal health. The answers can help identify potential issues of concern and target recommendations accordingly.
  • Diet and Nutrition: Please mark all that apply
  • Do you cook meals at home from scratch?*

  • Activity and Lifestyle

  • Do you sweat when you exercise?*
  • Do you sweat minimal, moderate or heavy?*
  • Do you feel rested when you wake up in the morning?*
  • Are you currently experiencing high levels of stress?*
  • Rank the amount of stress from 1-10, with 1 being none and 10 being a tremendous amount:*

  • Part 2

    This part will help identify which parts of the digestive tract are causing the most problems or symptoms. Please enter in the number that best describes the severity of the symptoms listed below. If you do not know the answer then leave it blank.
  • Rows

  • Score 0-4: Low Priority, Score 5-9: Moderate Priority, Score 10 or above: High Priority

  • Rows

  • Score 0-6: Low Priority, Score 6-10: Moderate Priority, Score 10 or above: High Priority

  • Rows

  • Score 0-3:  Low Priority, Score 4-6:  Moderate Priority, Score 7 or above:  High Priority

  • Rows

  • Score 0-4:  Low Priority, Score 5-8:  Moderate Priority, Score 9 or above: High Priority

  • Rows

  • Score 0-2:  Low priority, Score 5-9:  Moderate Priority, Score 10 or above:  High Priority 

  • Rows

  • Score 1-5:  Low priority, Score 6-10:  Mild Priority, Score 7-19:  Moderate Priority, Score 20 or above:  High Priority

  • Rows

  • Score 0-4:  Low priority, Score 5-9:  Moderate Priority, Score 10 or above:  High Priority

  • Rows

  • Score 0-6:  Low Priority, Score 6-10:  Moderate Priority, Score 10 or above:  High Priority 

  • Rows

  • Score 1-5:  Low Priority, Score 6-10:  Mild Priority, Score 7-19: Moderate Priority, Score 20 or above:  High Priority

     

  • Rows

  • Score 0-6:  Low Priority, Score 6-10:  Moderate Priority, Score 10 or above:  High Priority

  • Rows

  • Score 0-5:  Low Priority, Score 6-9:  Moderate Priority, Score 10 or above:  High Priority

  • Should be Empty: