Gut Health Questionnaire

Gut Health Questionnaire

Derinda Stevenson - (817) 980-9108
This questionnaire will help provide a better understanding of your gut health issues and goals, which can inform the best recommendations for your supplement regiments.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Age

1. How often do you experience the following symptoms? Please select the most accurate answer.

2. Bowel Movement Frequency - On average, how often do you have a bowel movement?
3. Water Intake - How much water do you drink on an average day?

4. Dietary Habits - How often do you consume the following foods?

Rows	Never	Rarely	Sometimes	Often	Always
Processed Foods
Refined Sugar
High Fiber Foods (Fruits & Vegetables)
Whole Grains

5. Stress Levels - On a scale of 1 to 5, how would you rate your current stress levels?

1

2

3

4

5

1 is Worst, 5 is Best
6. Sleep Patterns - How many hours of sleep do you typically get at night?
7. Gut Health Goals - What are your primary gut health goals? (Select all that apply)

Other
8. Previous Gut Health Solutions - Have you tried any gut health solutions in the past?
9. Additional Information - Please share anything else about your gut health journey that you think is important:
Should be Empty: