14 day Gut program eligibility form

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14 day Gut program eligibility form

1
Full Name
First Name
Last Name
2
What is your age?
3
What is your gender?
Please Select
Please Select
Male
Female
N/A
4
Contact Number
5
Email Address
example@example.com
6
Tick gut conditions that apply to you
indigestion
uncomfortable bloating/gas
stomach pain
diagnosed with IBS
acid reflux
loose bowel once a month
constipation/hard stool
mucous in stool
floating stool
smelly stool
burping/belching
Other
7
Tick other symptoms you are currently experiencing:
fatigue after a meal
sensitivity towards chemicals/fragrances
common headaches
bad breath
difficulty losing weight
mood swings/depression
seasonal allergies
antibiotics more than a 10 day course
antibiotics more than 3 times a year
brain fog
sleepy during the day
white layer on tongue
acne
rashes
sweet cravings (not occasional)
disturbed sleep
8
Tick the medical conditions/ medications applicable:
steroid medication
use of nasal sprays/inhalers
diagnosed with diabetes
diagnosed with autoimmune disease
throat infections as a child
Should be Empty:

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