Welcome to Unlocking GI

Welcome to Unlocking GI
We’re so glad you’re here!

At Unlocking GI, we believe in a whole-person approach to digestive health—grounded in the 4Ms: Medical, Meals, Mindset, and Movement. This short survey is your starting point.

Once complete, you’ll have the opportunity to book a FREE Personalized 45-minute consultation with Dr. Leybelis Padilla, who will personally review your responses and walk you through tailored insights that could help you feel better—often in ways traditional care overlooks.

Some people choose to stay connected through our free community. Others are ready for daily, personalized support with Dr. Padilla. Either way, this is your invitation to take a clearer, more empowered next step. Let’s begin!
Full Name*

First NameLast Name
What is your date of birth?*

MonthDayYear
Date
What was your assigned sex at birth?*
Contact Number*
Email Address*
example@example.com
Enter your zip code: *
In the last week how would you rate your overall wellbeing? 1= Worst (asking yourself how did I get here?); 2 = Slightly Unwell; 3 = Ok (Balance of good and bad days); 4= Getting by but could be better; 5 = Generally Well*

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1 is Worst, 5 is Well
What are the specific health or wellness goals you are looking to evaluate and improve? These may encompass the 4Ms: Medical, Meals, Mindset, and Movement. Feel free to elaborate! I will read it all! *
🩺 Medical
How much of a priority is improving and understanding your digestive symptoms, medical conditions, and collaborating actively on a personalized care plan? This means personalized explanations of your condition, strategic, root-cause and preventative medical guidance including lab and imaging testing when necessary. 10= A strong priority; 1= I got it all covered.

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1 is All Set, 10 is Strong Priority
Are you currently taking any medications including prescribed medications, over the counter medications and/or supplements?*

YesNo
Please list them. Please include dosing and frequency if you can.*
Do you use any kind of tobacco or have you ever used them?*
What kind of tobacco products? When did you use them and for how long?*
How often do you have a drink containing alcohol?*

NeverMonthly or less2-4x per month2-3x per week4 or more times per week
How many alcohol containing drinks do you have on a typical day when drinking?

1 or 23 or 45 or 67 to 910 or more
How often do you have six or more drinks on one occasion?

NeverLess than monthlyMonthlyWeeklyDaily or Almost daily
Have you ever been diagnosed with the following specific Gastrointestinal conditions? Select all that apply. *
Approximately, how long have you been experiencing gastrointestinal challenges? Don't need to be exact on this one, just give me a good estimate.*

Within the last yearMore than 1 year ago, but less than 3 years agoMore than 3 years ago, but less than 10 years agoI'm an OG and it's been more than 10 years ago!
On a scale of 1 to 5, how good are you at remembering to take your prescribed medications? If not on any medications, leave blank.

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5

1 is Inconsistent, 5 is Perfect
Do you feel like it is difficult finding reliable and accurate information specifically relevant to your personal situation?*

YesNo
Are there specific topics or things surrounding your gastrointestinal condition you want to learn more about?*
Do you ever see blood in your stool?*

No blood seenStreaks of blood seen with stoolsObvious blood with stool most of the time
In the last 3 months, have you had stomach or abdominal pain at least 1 day per week?*

YesNo
Does your abdominal pain improve or worsen after having a bowel movement?*

YesNo
When you have pain, do you notice you poop more often or less often than usual?*

YesNo
When you have pain, does the consistency of your stool change (harder, looser, or different shape)?*

YesNo
Are your bowel movements unpredictable?*

YesNo
Are your bowel movements usually hard or firm (constipated)?*

YesNo
Are they usually loose or runny (diarrhea)?*

YesNo
If yes, do your loose stools/diarrhea ever awaken you up from sleep?*

YesNo
Do you feel full quickly when eating (early satiety)?*

YesNo
Do you have any symptoms of gas / bloating?*

YesNo
Do you have any issues with swallowing your food such as the sensation of food and/or liquids getting stuck after eating?*

YesNo
List any other medical conditions you may have not previously mentioned (Such as high blood pressure, diabetes, heart disease, asthma, etc).*
Please list prior surgeries (no need to be too specific). If none, please state N/A or not applicable.*
Do any of your 1st degree family members (parents/siblings) have a history of gastrointestinal (GI) conditions? For example: colon cancer, pancreatic cancer, stomach issues, liver disease or liver cancer, esophageal disorders, inflammatory bowel disease or pancreas-related problems.*
🥗 Meals
How much of a priority is improving your food choices and nutrition right now? This means learning how to read food labels, making healthier meal and/or ingredient choices, eating more consciously, and using food as medicine. 10= A strong priority; 1= I got it all covered. *

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1 is All Set, 10 is Strong Priority
Do you follow any specific diet?*
Where do you feel your biggest source of protein is from? Select all that apply.*

Eating animal protein is my jamI dabble with meat (it's more like my side dish)I eat mostly fishI get most of my protein from plantsI don't even know!Other
Specifically, do you avoid gluten?*

YesNoWhat is gluten?!
Have you noticed any specific foods or beverages that seem to cause or exacerbate your symptoms? Please list a few common experiences or reactions.*
Have you experienced any unintentional weight loss recently? If so, how much and over what time period?*
Have you noticed any signs that suggest you might not be absorbing nutrients effectively, such as fatigue, brittle nails, hair loss, or pale skin?*

YesNo
Can you think of 2 habits in your life that are food/nutrition focused that you would be interested in changing?*
🧠 Mindset
How much of a priority is improving your mindset right now? This means potentially learning habit building skills, mindfulness tools, negative beliefs holding you back, and meditation, and more. 10= A strong priority; 1= I got it all covered.*

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1 is All Set, 10 is Strong Priority
What are some things that you engage in that you consider self-care? (for example, reading a book, listening to music, exercise, getting a massage, going for a walk?)*
Do you feel emotionally supported in your health journey?*
How would you rate your quality of sleep?*

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1 is What is sleep?, 5 is Like a baby!
On average, how many hours of sleep do you get per night?*

Less than or equal to 5 hours6 to 8 hoursMore than 8 hours
Do you use any of the following tools or practices to calm your mind and spirit? Select all that apply.

MeditationMindfulnessPrayerNoneOther
How many times per week do you engage in meditation, mindfulness practices, or prayer?*

1 time per week2 - 3 times per week3 or more times per weekUm, who has time for that?!Not applicable
Have you noticed a connection between your emotional state and your digestive symptoms? If so, please briefly describe.*
How often have you been bothered by the following the past 2 weeks?
Little Interest or pleasure in doing things?*

Not at allSeveral daysMore than half the daysNearly every day
Feeling down, depressed, or hopeless?*

Not at allSeveral DaysMore than half the daysNearly every day
Trouble falling or staying asleep, or sleeping too much?*

Not at allSeveral DaysMore than half the daysNearly every day
Feeling tired or having little energy*

Not at allSeveral DaysMore than half the daysNearly every day
Poor appetite or overeating?*

Not at allSeveral DaysMore than half the daysNearly every day
Feeling bad about yourself - or that you are a failure or have let yourself or your family down?*

Not at allSeveral DaysMore than half the daysNearly every day
Trouble concentrating on things, such as reading the newspaper or watching TV?*

Not at allSeveral DaysMore than half the daysNearly every day
Moving or speaking slowly that other people could have noticed? Or so fidgety or restless that you have been moving a lot more than usual?*

Not at allSeveral DaysMore than half the daysNearly every day
Thoughts that you would be better off dead, or thoughts of hurting yourself in some way? The 988 Lifeline is a national network of local crisis centers that provides free and confidential emotional support to people in suicidal crisis or emotional distress 24 hours a day, 7 days a week in the United States. We're committed to improving crisis services and advancing suicide prevention by empowering individuals, advancing professional best practices, and building awareness.*

Not at allSeveral DaysMore than half the daysNearly every day
🏃‍♀️ Movement
How much of a priority is improving your musculoskeletal health such as strength, flexibility, and stability? This means creating systems for accountability, building consistent movement routines, exploring mindset blocks that impact physical activity, and integrating tools like yoga and pilates. 10= A strong priority; 1= I got it all covered. *

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1 is All Set, 10 is Strong Priority
How many times per week do you engage in intentional stretching or flexibility-focused practices such as yoga, pilates, or other flexibility exercises?*

3 or more times per week2 - 3 times per week1 time per weekA few times per monthMonthlyNot exercising with any regular frequency
How strong would you describe your core strength? This is your abdominal wall muscles and lower back strength.*

Core strength what?!I can prob do 5 crunches and I am done.Can do 5 - 10 crunches and can hold a plank pose for at least 1 minProud to say I am beach body ready!
How easily can you perform everyday movements that matter to you—like getting off the floor, walking up stairs, or lifting groceries? 1 = very difficult, 10 = effortless*

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1 is Very difficult, 10 is Effortless
How stable do you feel during everyday movements like balancing on one leg, reaching overhead, or changing directions quickly? 1 = very difficult, 10 = effortless*

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1 is Very difficult, 10 is Effortless
Do you notice stiffness or pain after sitting, sleeping, or staying in one position for too long?*

YesNo
When it comes to physical activity, what are some goals you would like to see happen for yourself?*
Should be Empty:

Welcome to Unlocking GI

How often have you been bothered by the following the past 2 weeks?