Gut Health and Symptoms Assessment
Name
*
First Name
Last Name
Email
*
Confirmation Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Select any of the following categories that you feel accurately represent your racial or ethnic identity. Check all that apply.
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Hispana Latino/a
Asian
Black or African
American Indian or Alaska Native
White or European
Middle East or North Africa
Pacific Islander
Prefer not to say
Other
Have you had a menstrual cycle in the last 12 months?
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Yes
No
Which of the following best describes your current stage? (Please select one)
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Perimenopause
Menopause
What is your age?
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Are any of the following ALERT Symptoms present? (if yes, see your doctor)
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Blood in stool
Unexplained weight loss
Anemia
Sudden change in bowel habits
Bowel movements/abdominal pain waking you up at night
New GI symptoms that do not improve in 2 weeks
N/A
Do you have any of the following confirmed gastrointestinal (GI) diagnoses? (Please select all that apply)
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IBS mixed
IBS- D (IBS with diarrhea)
IBS-C (IBS with constipation)
Dyspepsia
Gastroparesis
Gallstones
IBD
Reflux
Hemorrhoids/Fissure
N/A
Other
How would you describe your bowel movements? (Please select all that apply)
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Normal and Fine: I experience regular bowel movements without any discomfort.
Small Hard Lumps: My stools are often hard and formed into small lumps.
Straining and Incomplete Emptying: I often have to strain during bowel movements and feel like I cannot empty my bowels completely.
Infrequent Movements: I go many days between bowel movements.
Frequent Loose, Urgent Stools: I experience loose stools with a sense of urgency quite frequently.
Loose Stools with Accidents: I have loose stools and have experienced accidents.
Alternating, Mainly Loose (Type 5-6): My bowel movements alternate, but they are mainly loose.
Alternating, Mainly Hard (Type 2-4): My bowel movements alternate, but they are mainly hard.
How would you describe your experience with bloating? (Please select all that apply)
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No Bloating or Gas: My belly remains flat, and I do not experience any issues with gas.
Bloating Worsens After Eating: I notice my bloating increases significantly after meals.
Improves After a Bowel Movement: My bloating tends to improve after I have a bowel movement.
Frequent Gas Passage: I pass a lot of gas throughout the day.
Belching or Burping is My Main Symptom: I experience frequent belching or burping, which is the primary way my bloating manifests.
Do you experience any of the following symptoms? (Please select all that apply)
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Lower Abdominal Pain
Upper Abdominal Pain
Heartburn
Rectal Symptoms
Nausea/Vomiting
N/A
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Medication and Gynecological History
Are you currently taking any of the following? (Please select all that apply)
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Fiber Supplements: Such as Benefiber, Psyllium Husk, Citrucel, Metamucil, etc
Magnesium Supplements: Including any form of magnesium taken for health purposes
Miralax: Or similar over-the-counter osmotic laxatives
Laxatives: Including senna, stimulant laxatives, or any other type
Probiotics: Supplements intended to support digestive health
Gas Relief Products: Such as Gas-X, Beano, or similar
N/A
Are you on oral contraceptives or estrogen-blocking agents such as Tamoxifen?
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Yes
No
Please indicate any of the following that apply to your gynecological history: (Select all that apply)
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Abnormal Menstrual Cycles
PCOS
History of Urinary/Bladder Problems
History of Endometriosis
History of Pelvic Floor Disorders
C-section
Vaginal delivery
N/A
How many days does your menstrual period typically last?
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3 days
4 days
5 days
6 days
7 days
8 days
N/A
Other
When was the start date of your last menstrual cycle?
How would you describe your menstrual cycles? (Please select all that apply)
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Painful: Experiencing discomfort or pain before, during, or after menstruation
Heavy: Having a high volume of menstrual flow, requiring frequent changes of sanitary products
Irregular: Experiencing cycles that vary significantly in length, making it difficult to predict when your period will start
Normal, Regular: Having cycles that are consistent in timing and flow, occurring with predictable frequency and duration
None: If you do not have menstrual cycles (applicable for reasons such as menopause, hysterectomy, hormonal treatments affecting menstruation, etc.)
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Lifestyle Factors: Diet, Exercise, and Sleep
Which of the following describes your usual dietary intake? (Please select all that apply)
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High Fiber
Low Fiber
Dairy
Caffeine
Sugar/Sweeteners
Excess raw fruits/vegetables
Alcohol (Etoh)
Gluten
High Acid Foods
N/A
Other
Are you following any specific diet? (Please select all that apply)
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FODMAP Diet
Mediterranean Diet
Plant-Based Diet
High Fiber Diet
Gluten-Free Diet
N/A
Other
How often do you engage in exercise?
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1-2 times per week
3-4 times per week
5-7 times per week
Rarely/Never
How would you describe the quality of your sleep?
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Good
So-So/Variable
Bad/Don't Sleep Well
How would you describe your general level of stress?
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None
Mild
Moderate
Severe
Which category best describes your current weight status based on Body Mass Index (BMI)?
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Normal/Average (BMI 20-24.99)
Overweight (BMI 25-29.99)
Obese (BMI >30)
Would you be willing to provide a stool sample for participation in a research study on women's microbiome health?
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Yes
No
Is there anything else about your health or lifestyle that you think is important for us to know?
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