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Digestive Health Survey
1.
Digestive Symptoms
Bloating, gas
Irregular Bowel
Abdominal Pain or Cramping
Heartburn or Acid Reflux
Nausea
Food Sentiivities
2.
How often do you experience bloating, gas, or stomach cramps? (Daily, a few times a week, a few times a month, rarely)
3.
Describe your typical bowel movements. Are they frequent, infrequent, loose, or difficult to pass?
4.
Do you notice any specific foods that trigger digestive discomfort? If so, what are they?
5.
Have you been diagnosed with any digestive conditions like IBS, Crohn's disease, or GERD?
6.
Do you take any medications or supplements to aid digestion?
7.
Physical & Other Symptoms
Unexplained Weight Fluctations
Stubborn Belly Fat
Unhealthy Cravings
Skin Issues
Joint Pain or Aches
Other (please specify)
8.
Mood and Mental Symptoms
Mood swings
Anxiety or irratability
Brain Fog
Fatigue
Depressive Feelings
Other (please specify)
9.
Do you have any sleep issues?
Difficulty falling asleep
Staying asleep
Waking up feeling unrefreshed
Other (please specify)
10.
Do you have uncontrollable cravings for processed foods?
Sugary foods or drinks
Fast foods
Late night snacks
Eating when not hungry
Other (please specify)