Do you have fewer than 3 bowel movements per week?

YES

NO

Do you have frequent loose, watery stool?

YES

NO

Is there undigested food in your stool?

YES

NO

Do you frequently suffer from a feeling of urgency (feeling that you must immediately rush to the toilet to pass a stool)?

YES

NO

Is your stool slimy (mucus) or oily?

YES

NO

Are you disturbed by pain or discomfort in your abdomen after eating?

YES

NO

Have your recently (over the past year) taken a round of antibiotics?

YES

No

Do you experience reflux of stomach contents? This often feels like a burning sensation in the throat, a sour or bitter taste, difficulty swallowing, or a dry cough..

YES

NO

Have you taken a medication for acid reflux (such as a PPI) over the past year?

YES

NO

Do you have a history of dieting, restricting a food group, or an eating disorder?

Yes

No

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Last Name

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