Gut Health Consultation Intake Form
Please complete this form to help us understand your symptoms, goals, and determine the next steps.
Basic Information
Full Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred method of communication
Text
Email
Phone
Tell Us Your Story
What are your biggest frustrations or concerns right now?
What are you hoping to better understand or improve?
What Have You Already Tried?
What have you already tried?
Elimination diets
Low-FODMAP diet
Gluten-free diet
Dairy-free diet
Probiotics or prebiotics
Digestive enzymes
Fiber supplements
Antacids or PPIs (Prilosec, Nexium, etc.)
Prescription gut medications
Working with a gastroenterologist
Working with a nutritionist or dietitian
Food sensitivity testing
Gut microbiome testing
Colonoscopy or endoscopy
Stress reduction or therapy
Nothing yet / not sure where to start
Other
Other
What worked, even a little?
What didn't work—or wasn't sustainable?
Medical History
Have you ever been diagnosed with any of the following?
IBS
IBD (Crohn's or Ulcerative Colitis)
SIBO
GERD or acid reflux
Celiac disease
Food allergies or intolerances
H. pylori infection
Fatty liver disease
Thyroid disorder
Anxiety or depression
Autoimmune disease
Diabetes or prediabetes
None of the above
Other
Other
What prompted your interest in a gut health consultation? (Check all that apply)
*
Bloating
Constipation
Diarrhea
Alternating constipation/diarrhea
Acid reflux / heartburn
Abdominal pain or discomfort
Gas or digestive discomfort
Food sensitivities
IBS symptoms
Fatigue or brain fog alongside digestive symptoms
Concern about inflammation
Difficulty losing weight / metabolism concerns
I want to better understand my gut health
Other
How long have these symptoms been present?
*
Less than 3 months
3–12 months
1–3 years
More than 3 years
How much are your symptoms affecting your daily life?
*
Mild
Moderate
Significant
Severe
Which symptoms are most bothersome right now? (Choose up to 3)
*
Bloating
Constipation
Diarrhea
Reflux / heartburn
Pain / discomfort
Fatigue
Brain fog
Food reactions
Weight concerns
Sleep disruption
Anxiety / stress around symptoms
Have you worked with any of the following? (Check all that apply)
*
Primary care physician
Gastroenterologist (GI specialist)
Functional medicine provider
Nutritionist / dietitian
Hormone clinic
None of the above
Have you had any of the following testing? (Check all that apply)
*
Colonoscopy
Endoscopy (EGD)
Celiac testing
Stool testing / GI-MAP
Food sensitivity testing
SIBO testing
Bloodwork
No prior testing
Unsure
Upload prior labs or reports (optional)
Upload a File
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Choose a file
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What best describes what you are hoping for?
*
I want to better understand what may be contributing to my symptoms
I want a whole-person approach to digestive health
I am interested in testing options
I want help identifying triggers and solutions
I'm not sure — I just know something feels off
Are you open to recommendations that may include lifestyle, nutrition, or additional testing?
*
Yes, I'd like more information
Unsure
Are you currently a member of Direct Primary Care of West Michigan?
*
Yes
No
What is your biggest concern or goal right now?
*
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