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Gastrointestinal Questionnaire
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* Indicates required question
Do you frequently suffer from gas, bloating, belching, constipation, or diarrhea?
Yes
No
If so, do you notice them occurring regularly after eating certain foods?
Yes
No
Do you have acid reflux or heartburn on a regular basis?
Yes
No
If so, do you notice it happening when you eat a particular type of food? (Check all that apply)
Sweet
Spicy
Meats/Proteins
Heavy Meals
Foods w/Acids
Other
What medications do you currently take?
Your answer
What is your age group
Between 18-24
Between 25-35
Between 36-45
Between 46-54
Between 55-64
Over 65
Clear selection
Do you have any food allergies or sensitivities?
Yes
No
Does your diet mostly consist of processed foods (foods from cans and boxes) rather than fresh (raw fruits and vegetables?)
Yes
No
First Name
*
Your answer
Last Name
*
Your answer
Email Address
*
Your answer
Phone #
*
Your answer
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