GI Health Assessment
This questionnaire asks you to assess how you have been feeling during the last four months. This information will help you keep track of how your physical, mental, and emotional states respond to changes you make in your eating habits, priorities, supplement program, social and family life, level of physical activity, and time spent on personal growth. All information is held in strict confidence. Take all the time you need to complete this questionnaire.
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Section A
1. Indigestion; food repeats on you after you eat
0 = No or rarely—You have never experienced the symptom, or the symptom is familiar to you, but you perceive it as insignificant (monthly or less)
1 = Occasionally—Symptom comes and goes and is linked in your mind to stress, diet, fatigue, or some other identifiable trigger
4 = Often—Symptom occurs 2-3x/week and/or with a frequency that bothers you enough that you would like to do something about it
8 = Frequently—Symptom occurs > 4x/week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis
2. Excessive burping, belching, and/or bloating following meals
0 = No or rarely—You have never experienced the symptom, or the symptom is familiar to you, but you perceive it as insignificant (monthly or less)
1 = Occasionally—Symptom comes and goes and is linked in your mind to stress, diet, fatigue, or some other identifiable trigger
4 = Often—Symptom occurs 2-3x/week and/or with a frequency that bothers you enough that you would like to do something about it
8 = Frequently—Symptom occurs > 4x/week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis
3. Stomach spasms and cramping during or after eating
0 = No or rarely—You have never experienced the symptom, or the symptom is familiar to you, but you perceive it as insignificant (monthly or less)
1 = Occasionally—Symptom comes and goes and is linked in your mind to stress, diet, fatigue, or some other identifiable trigger
4 = Often—Symptom occurs 2-3x/week and/or with a frequency that bothers you enough that you would like to do something about it
8 = Frequently—Symptom occurs > 4x/week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis
4. A sensation that food just sits in your stomach creating uncomfortable fullness, pressure, and bloating during or after a meal
0 = No or rarely—You have never experienced the symptom, or the symptom is familiar to you, but you perceive it as insignificant (monthly or less)
1 = Occasionally—Symptom comes and goes and is linked in your mind to stress, diet, fatigue, or some other identifiable trigger
4 = Often—Symptom occurs 2-3x/week and/or with a frequency that bothers you enough that you would like to do something about it
8 = Frequently—Symptom occurs > 4x/week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis
5. Bad taste in your mouth
0 = No or rarely—You have never experienced the symptom, or the symptom is familiar to you, but you perceive it as insignificant (monthly or less)
1 = Occasionally—Symptom comes and goes and is linked in your mind to stress, diet, fatigue, or some other identifiable trigger
4 = Often—Symptom occurs 2-3x/week and/or with a frequency that bothers you enough that you would like to do something about it
8 = Frequently—Symptom occurs > 4x/week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis
6. Small amounts of food fill you up immediately
0 = No or rarely—You have never experienced the symptom, or the symptom is familiar to you, but you perceive it as insignificant (monthly or less)
1 = Occasionally—Symptom comes and goes and is linked in your mind to stress, diet, fatigue, or some other identifiable trigger
4 = Often—Symptom occurs 2-3x/week and/or with a frequency that bothers you enough that you would like to do something about it
8 = Frequently—Symptom occurs > 4x/week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis
7. Skip meals or eat erratically because you have no appetite
0 = No or rarely—You have never experienced the symptom, or the symptom is familiar to you, but you perceive it as insignificant (monthly or less)
1 = Occasionally—Symptom comes and goes and is linked in your mind to stress, diet, fatigue, or some other identifiable trigger
4 = Often—Symptom occurs 2-3x/week and/or with a frequency that bothers you enough that you would like to do something about it
8 = Frequently—Symptom occurs > 4x/week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis
Section B
1. Strong emotions or the thought or smell of food aggravates your stomach or creates discomfort
0 = No or rarely—You have never experienced the symptom, or the symptom is familiar to you, but you perceive it as insignificant (monthly or less)
1 = Occasionally—Symptom comes and goes and is linked in your mind to stress, diet, fatigue, or some other identifiable trigger
4 = Often—Symptom occurs 2-3x/week and/or with a frequency that bothers you enough that you would like to do something about it
8 = Frequently—Symptom occurs > 4x/week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis
2. Feel hungry an hour or two after eating a good-sized meal
0 = No or rarely—You have never experienced the symptom, or the symptom is familiar to you, but you perceive it as insignificant (monthly or less)
1 = Occasionally—Symptom comes and goes and is linked in your mind to stress, diet, fatigue, or some other identifiable trigger
4 = Often—Symptom occurs 2-3x/week and/or with a frequency that bothers you enough that you would like to do something about it
8 = Frequently—Symptom occurs > 4x/week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis
3. Stomach discomfort and/or aching over a period of 1-4 hours after eating
0 = No or rarely—You have never experienced the symptom, or the symptom is familiar to you, but you perceive it as insignificant (monthly or less)
1 = Occasionally—Symptom comes and goes and is linked in your mind to stress, diet, fatigue, or some other identifiable trigger
4 = Often—Symptom occurs 2-3x/week and/or with a frequency that bothers you enough that you would like to do something about it
8 = Frequently—Symptom occurs > 4x/week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis
4. Stomach discomfort and/or aching relieved by eating food; drinking carbonated beverages, cream, or milk; or taking antacids
0 = No or rarely—You have never experienced the symptom, or the symptom is familiar to you, but you perceive it as insignificant (monthly or less)
1 = Occasionally—Symptom comes and goes and is linked in your mind to stress, diet, fatigue, or some other identifiable trigger
4 = Often—Symptom occurs 2-3x/week and/or with a frequency that bothers you enough that you would like to do something about it
8 = Frequently—Symptom occurs > 4x/week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis
5. Uncomfortable sensation in the lower part of your chest, especially when lying down or bending forward
0 = No or rarely—You have never experienced the symptom, or the symptom is familiar to you, but you perceive it as insignificant (monthly or less)
1 = Occasionally—Symptom comes and goes and is linked in your mind to stress, diet, fatigue, or some other identifiable trigger
4 = Often—Symptom occurs 2-3x/week and/or with a frequency that bothers you enough that you would like to do something about it
8 = Frequently—Symptom occurs > 4x/week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis
6. If digestive problems are present, these subside with rest and relaxation
Yes
No
7. Eating spicy and fatty (fried) foods, chocolate, coffee, alcohol, citrus, or hot peppers causes your stomach to ache
0 = No or rarely—You have never experienced the symptom, or the symptom is familiar to you, but you perceive it as insignificant (monthly or less)
1 = Occasionally—Symptom comes and goes and is linked in your mind to stress, diet, fatigue, or some other identifiable trigger
4 = Often—Symptom occurs 2-3x/week and/or with a frequency that bothers you enough that you would like to do something about it
8 = Frequently—Symptom occurs > 4x/week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis
8. Feel a sense of mild nausea when you eat
0 = No or rarely—You have never experienced the symptom, or the symptom is familiar to you, but you perceive it as insignificant (monthly or less)
1 = Occasionally—Symptom comes and goes and is linked in your mind to stress, diet, fatigue, or some other identifiable trigger
4 = Often—Symptom occurs 2-3x/week and/or with a frequency that bothers you enough that you would like to do something about it
8 = Frequently—Symptom occurs > 4x/week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis
9. Difficulty or discomfort when swallowing food or beverage
0 = No or rarely—You have never experienced the symptom, or the symptom is familiar to you, but you perceive it as insignificant (monthly or less)
1 = Occasionally—Symptom comes and goes and is linked in your mind to stress, diet, fatigue, or some other identifiable trigger
4 = Often—Symptom occurs 2-3x/week and/or with a frequency that bothers you enough that you would like to do something about it
8 = Frequently—Symptom occurs > 4x/week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis
Section C
1. When massaging under your rib cage, there is tenderness
0 = No or rarely—You have never experienced the symptom, or the symptom is familiar to you, but you perceive it as insignificant (monthly or less)
1 = Occasionally—Symptom comes and goes and is linked in your mind to stress, diet, fatigue, or some other identifiable trigger
4 = Often—Symptom occurs 2-3x/week and/or with a frequency that bothers you enough that you would like to do something about it
8 = Frequently—Symptom occurs > 4x/week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis
2. Indigestion, fullness, or tension in your abdomen is delayed, occurring 2-4 hours after eating a meal
0 = No or rarely—You have never experienced the symptom, or the symptom is familiar to you, but you perceive it as insignificant (monthly or less)
1 = Occasionally—Symptom comes and goes and is linked in your mind to stress, diet, fatigue, or some other identifiable trigger
4 = Often—Symptom occurs 2-3x/week and/or with a frequency that bothers you enough that you would like to do something about it
8 = Frequently—Symptom occurs > 4x/week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis
3. Lower abdominal discomfort is relieved with the passage of gas or with a bowel movement
0 = No or rarely—You have never experienced the symptom, or the symptom is familiar to you, but you perceive it as insignificant (monthly or less)
1 = Occasionally—Symptom comes and goes and is linked in your mind to stress, diet, fatigue, or some other identifiable trigger
4 = Often—Symptom occurs 2-3x/week and/or with a frequency that bothers you enough that you would like to do something about it
8 = Frequently—Symptom occurs > 4x/week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis
4. The consistency or form of your stool changes (e.g., from narrow to loose) within the course of a day
0 = No or rarely—You have never experienced the symptom, or the symptom is familiar to you, but you perceive it as insignificant (monthly or less)
1 = Occasionally—Symptom comes and goes and is linked in your mind to stress, diet, fatigue, or some other identifiable trigger
4 = Often—Symptom occurs 2-3x/week and/or with a frequency that bothers you enough that you would like to do something about it
8 = Frequently—Symptom occurs > 4x/week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis
5. Specific foods/beverages aggravate indigestion
0 = No or rarely—You have never experienced the symptom, or the symptom is familiar to you, but you perceive it as insignificant (monthly or less)
1 = Occasionally—Symptom comes and goes and is linked in your mind to stress, diet, fatigue, or some other identifiable trigger
4 = Often—Symptom occurs 2-3x/week and/or with a frequency that bothers you enough that you would like to do something about it
8 = Frequently—Symptom occurs > 4x/week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis
6. Stool odor is embarrassing
0 = No or rarely—You have never experienced the symptom, or the symptom is familiar to you, but you perceive it as insignificant (monthly or less)
1 = Occasionally—Symptom comes and goes and is linked in your mind to stress, diet, fatigue, or some other identifiable trigger
4 = Often—Symptom occurs 2-3x/week and/or with a frequency that bothers you enough that you would like to do something about it
8 = Frequently—Symptom occurs > 4x/week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis
7. Undigested food in your stool
0 = No or rarely—You have never experienced the symptom, or the symptom is familiar to you, but you perceive it as insignificant (monthly or less)
1 = Occasionally—Symptom comes and goes and is linked in your mind to stress, diet, fatigue, or some other identifiable trigger
4 = Often—Symptom occurs 2-3x/week and/or with a frequency that bothers you enough that you would like to do something about it
8 = Frequently—Symptom occurs > 4x/week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis
8. Three or more large bowel movements daily
0 = No or rarely—You have never experienced the symptom, or the symptom is familiar to you, but you perceive it as insignificant (monthly or less)
1 = Occasionally—Symptom comes and goes and is linked in your mind to stress, diet, fatigue, or some other identifiable trigger
4 = Often—Symptom occurs 2-3x/week and/or with a frequency that bothers you enough that you would like to do something about it
8 = Frequently—Symptom occurs > 4x/week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis
9. Frequent loose, watery stool
0 = No or rarely—You have never experienced the symptom, or the symptom is familiar to you, but you perceive it as insignificant (monthly or less)
1 = Occasionally—Symptom comes and goes and is linked in your mind to stress, diet, fatigue, or some other identifiable trigger
4 = Often—Symptom occurs 2-3x/week and/or with a frequency that bothers you enough that you would like to do something about it
8 = Frequently—Symptom occurs > 4x/week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis
10. Bowel movement shortly after eating (within 1 hour)
0 = No or rarely—You have never experienced the symptom, or the symptom is familiar to you, but you perceive it as insignificant (monthly or less)
1 = Occasionally—Symptom comes and goes and is linked in your mind to stress, diet, fatigue, or some other identifiable trigger
4 = Often—Symptom occurs 2-3x/week and/or with a frequency that bothers you enough that you would like to do something about it
8 = Frequently—Symptom occurs > 4x/week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis
Section D
1. Discomfort or cramps in your colon (lower abdominal area)
0 = No or rarely—You have never experienced the symptom, or the symptom is familiar to you, but you perceive it as insignificant (monthly or less)
1 = Occasionally—Symptom comes and goes and is linked in your mind to stress, diet, fatigue, or some other identifiable trigger
4 = Often—Symptom occurs 2-3x/week and/or with a frequency that bothers you enough that you would like to do something about it
8 = Frequently—Symptom occurs > 4x/week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis
2. Emotional stress and/or eating raw fruits and vegetables causes abdominal bloating, cramps, or gas
0 = No or rarely—You have never experienced the symptom, or the symptom is familiar to you, but you perceive it as insignificant (monthly or less)
1 = Occasionally—Symptom comes and goes and is linked in your mind to stress, diet, fatigue, or some other identifiable trigger
4 = Often—Symptom occurs 2-3x/week and/or with a frequency that bothers you enough that you would like to do something about it
8 = Frequently—Symptom occurs > 4x/week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis
3. Occasionally constipated (or straining during bowel movements)
0 = No or rarely—You have never experienced the symptom, or the symptom is familiar to you, but you perceive it as insignificant (monthly or less)
1 = Occasionally—Symptom comes and goes and is linked in your mind to stress, diet, fatigue, or some other identifiable trigger
4 = Often—Symptom occurs 2-3x/week and/or with a frequency that bothers you enough that you would like to do something about it
8 = Frequently—Symptom occurs > 4x/week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis
4. Stool is small, hard, and dry
0 = No or rarely—You have never experienced the symptom, or the symptom is familiar to you, but you perceive it as insignificant (monthly or less)
1 = Occasionally—Symptom comes and goes and is linked in your mind to stress, diet, fatigue, or some other identifiable trigger
4 = Often—Symptom occurs 2-3x/week and/or with a frequency that bothers you enough that you would like to do something about it
8 = Frequently—Symptom occurs > 4x/week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis
5. Pass mucus in your stool
0 = No or rarely—You have never experienced the symptom, or the symptom is familiar to you, but you perceive it as insignificant (monthly or less)
1 = Occasionally—Symptom comes and goes and is linked in your mind to stress, diet, fatigue, or some other identifiable trigger
4 = Often—Symptom occurs 2-3x/week and/or with a frequency that bothers you enough that you would like to do something about it
8 = Frequently—Symptom occurs > 4x/week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis
6. Alternate between occasional constipation and diarrhea
0 = No or rarely—You have never experienced the symptom, or the symptom is familiar to you, but you perceive it as insignificant (monthly or less)
1 = Occasionally—Symptom comes and goes and is linked in your mind to stress, diet, fatigue, or some other identifiable trigger
4 = Often—Symptom occurs 2-3x/week and/or with a frequency that bothers you enough that you would like to do something about it
8 = Frequently—Symptom occurs > 4x/week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis
7. Rectal itching or cramping
0 = No or rarely—You have never experienced the symptom, or the symptom is familiar to you, but you perceive it as insignificant (monthly or less)
1 = Occasionally—Symptom comes and goes and is linked in your mind to stress, diet, fatigue, or some other identifiable trigger
4 = Often—Symptom occurs 2-3x/week and/or with a frequency that bothers you enough that you would like to do something about it
8 = Frequently—Symptom occurs > 4x/week and/or you are aware of the symptom every day, or it occurs with regularity on a monthly or cyclical basis
8. No urge to have a bowel movement
Yes
No
9. An almost continual need to have a bowel movement
Yes
No
Submit
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