QUIZ: Gut Health Intake Form – The Essential Elements

I have personally experienced digestive issues such as bloating and gas. *

True

False

Have you experienced any of the following digestive symptoms in the past few months? Select all that apply *

Gas

Bloating

Cramping

Diarrhea

Constipation

None of the above

I have noticed unintentional changes in your weight recently. *

True

False

I frequently experience food cravings, especially for sugary foods. *

True

False

How would you describe your energy levels on a daily basis? *

Sluggish, low energy

Average, moderate energy

Peppy, high energy

Inconsistent from day

Have you been diagnosed with food allergies or experienced symptoms like abdominal pain, diarrhea, or nausea after eating certain foods? *

Yes

No

Are you aware of your chewing habits and how many times you typically chew your food? *

Yes, I chew thoroughly

I'm aware, but I don't chew thoroughly

No, I don't pay attention to it

Do you typically consume liquids, like water or beverages, with your meals? *

Yes, I always drink with my meals

Sometimes, I occasionally have liquids with meals

No, I avoid drinking during meals

Which of the following activities best describes what you are usually doing when you are eating? *

Multitasking, like watching TV or reading

Engaging in conversation

Focusing solely on eating without distractions

How frequently do you consume leftovers in your daily meals? *

Daily

A few times a week

Occasionally

Rarely

Never

How frequently do you experience symptoms like heartburn or acid reflux? *

Never

Rarely

Occasionally

A few times a week

Daily

Have you been diagnosed with conditions like Irritable Bowel Syndrome (IBS) or Inflammatory Bowel Disease (IBD)? *

Yes

No

Describe any specific digestive issues or symptoms you have experienced recently. (100 to 1,200 characters) *

Are there any recent changes in your lifestyle or diet that you believe may have affected your digestive health? (100 to 1,200 characters) *

Have you heard about the gut-brain connection and its potential impact on mood and mental health? *

Yes

No

What are you doing now to support your gut health? (100 to 1,200 characters) *