GI Questionnaire
Before filling out any questionnaires, please print and sign the forms under the Patient Forms tab at http://www.drjonesbailey.com. Bring them to your next appointment with Dr. Alise Jones-Bailey. Thank you.
Patient name *
Your answer
Date of Birth
MM
/
DD
/
YYYY
Please list your top 3 major health concerns in order of importance:
Your answer
DIET AND GASTROINTESTINAL HEALTH: Do you consume at least five servings of fruits and vegetables per day?
Do you drink at least 8 oz glasses of water every day?
Do you regularly consume soft drinks or fruit juices?
DIGESTION AND ABSORPTION: Do you experience frequent heartburn, burping, gas, or bloating during or immediately after meals?
Have you ever been diagnosed with anemia or any other nutrient deficiency?
Have you ever been placed on a heartburn medication (proton pump inhibitor(PPI) or H2 blocker)?
Do you frequently experience indigestion?
ELIMINATION AND DETOXIFICATION: Do you regularly have less than one or more than three bow
Do you take a laxative more than twice a month?
Are you sensitive to smells or fragrances?
Do you have regular exposure to exhaust fumes, tobacco smoke, pesticides, commercial chemicals, pant, cleaning or volatile fumes?
MICROBIAL BALANCE: Have you used antibiotics within the past two years?
Do you experience abdominal bloating, pain, gas, constipation or diarrhea?
Have you ever been diagnosed with chronic fatigue syndrome, fibromyalgia or irritable bowel syndrome?
Do you experience poor memory, difficulty concentrating or brain fog?
BARRIER FUNCTION: Have you ever been diagnosed with depression, anxiety, ADD or ADHD?
Do you suffer from multiple food sensitivities?
Do you experience skin issues such as acne, rosacea or eczema?
Do you have seasonal allergies, asthma or an autoimmune disease?
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service