Screening Questionnaire

1
What brings you to inFoods IBS today?* This field is required.
I'm feeling bloated
I'm feeling gastrointestinal pain
I'm feeling bloated & gastrointestinal pain
Diarrhea, constipation or other bowel discomfort
I would like to know which foods are triggering my discomfort
2
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3
Over the past 7 days, I have felt gastrointestinal pain and bloating.* This field is required.
Every day (Almost Always)
5 of the 7 days (Usually)
3 of the 7 days (Often)
Rarely
Never
4
I have been suffering from IBS-like symptoms (Gastrointestinal Pain, Bloating, other) for...* This field is required.
0-6 Months
6-12 Months
1-3 Years
More than 3 Years
Never
5
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6
Which of the following treatments are you currently using or have tried in the past to manage your IBS symptoms?* This field is required.Select all that apply
Prescription & Over the Counter (OTC) Medications
Fiber and other Supplements
Low FODMAP Diet or other Specialty Diets
Trial and Error Elimination Diets
Non-proven food sensitivity testing
Yoga and/or regular exercise
Life Coaching
Hypnotherapy
Acupuncture
Medical Marijuana
Other
No treatment at all
7
What prescription drugs or OTC medications have you taken?
Linzess
Amitiza
Xifaxan
Viberzi
Lontronex
Other
None
8
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9
Do any of the following apply to you?* This field is required.
Are you under 18 years old?
Do you currently have a diagnosed eating disorder?
Do you have unexpected blood in the stool? (Not hemorrhoids)
Have you been experiencing unexpected weight loss?
None of the above.
10
Thanks for Sharing* This field is required.inFoods IBS doesn't appear to be a fit for you at this time based on the conditions you indicated in this form. Speak with your doctor then get back in touch!
Sounds good
11
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12
inFoods IBS could be a great fit for you. * This field is required.By clicking “Next” below, you acknowledge that you have read, understood, and accepted the Privacy Policy (including sensitive data processing) and agree to receive additional information on the inFoods IBS program.
example@example.com
13
Full Name:* This field is required.
First Name
Last Name
14
Select a state* This field is required.Let's see if the inFoods IBS is available in your state.
Select a state
Select a state
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
15
We're not in your state quite yet* This field is required.We'll reach out as soon as we're nearby
Okay, keep me posted
16
Finally, how did you hear about us?* This field is required.
Facebook
Instagram
TikTok
Google Search
Word of mouth or referred by inFoods IBS client
Referred by my doctor, physician, or other provider
17
Which medical provider referred you to inFoods IBS?* This field is required.
18
inFoods IBS is a great fit for you
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