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Clinical Digestive Health Assessment
Complete your medical questionnaire to begin your personalized GI treatment plan
Step 1: Basic Information
Full Name
Email Address
Age
Select your age range
18-24
25-34
35-44
45-54
55-64
65+
Biological Sex
Male
Female
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Step 2: Your Digestive Symptoms
Which symptoms do you regularly experience?
Bloating
Excessive gas
Heartburn/Acid reflux
Constipation
Diarrhea
Abdominal pain
Nausea
How often do these symptoms occur?
Daily
A few times a week
A few times a month
Occasionally
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Step 3: Your Diet & Lifestyle
How would you describe your diet?
Omnivore (meat & vegetables)
Vegetarian
Vegan
Keto/Low-carb
Paleo
Other
How many glasses of water do you drink daily?
Select an option
0-2 glasses
3-5 glasses
6-8 glasses
More than 8 glasses
How would you rate your stress level?
Low
Moderate
High
Very High
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Step 4: Your Medical History
Have you been diagnosed with any of the following?
Irritable Bowel Syndrome (IBS)
Inflammatory Bowel Disease (IBD)
Gastroesophageal Reflux Disease (GERD)
Celiac Disease
Small Intestinal Bacterial Overgrowth (SIBO)
None of the above
Are you currently taking any medications?
What are your main goals for improving your digestive health?
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