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Survey

Have you been diagnosed with any of the following?

Diverticulitis
Colitis
Crohn's
IBD
IBS
Celiac
No formal diagnosis, just having some symptoms I'd like to fix

How old are you?

Under 20 years old
21-30
31-40
41-50
51-60
61-70
Over 70 years

How old were you when you started experiencing negative digestive symptoms?

20 or younger
21-30
31-40
41-50
Over 50

How many rounds of antibiotics have you taken in the last 5 years? (For any reason, not just digestive issues.

0
1
2
3+

How often do you exercise, even if it's because your job requires physical activity?

Daily
A few times per weekbr> Almost never
Never

Let's talk about your diet for a moment... How many times each week do you consume fresh fruits or vegetables?

Multiple times each day
I get fruits and veggies in at least once each day
A few times per week when I have time
I don't eat raw or fresh fruits and vegetables

How many times per week do you eat fast food?

Never
1-3 Times Weekly
More than 3 Times Per Week

Where do you usually eat?

I cook daily and eat at home
I'm on the go so I'm eating out of the house regularly
I mix it up, sometimes I have time and eat at home but I do eat out frequently

How willing are you to try a new way of eating or a diet?

Some people easily adjust and modify their eating while others are very particular about how they eat, we can work with both types, but we need to know how you feel about this.

I'm at the point where I'll do anything to feel great, just tell me how to eat.
I might try a diet if I don't have to drop my favorite foods and I can cheat sometimes.
I like what I like and I'm not likely to change how I eat.

How is your weight?

I'm too thin and trying to put on a few pounds
I'm trying to loose some weight
My weight is healthy, not trying to go up or down

Do you ever have bloating or uncomfortable swelling in your stomach?

Yes
No

Does your lower stomach/intestine area ever feel bloated or uncomfortable?

Yes
No

Do you regularly have diarrhea for more than 3 days?

Yes
No

Do you experience constipation?

Yes
No

Are you currently taking anything for regularity? (a fiber supplement for example)

Yes
No

Do you experience digestive flare ups?

Times when your body is extremely digestively off in a way that prohibits your normal daily activities.

Yes, I'm having one right now
Yes, I'm not having one now but I experience them occasionally
No, I've never had a flare up

Do you ever experience excessive gas or does your gas seem to have an unusually unpleasant odor?

Yes
No

Is acid reflux an issue for you?

Yes
No

Do you ever experience heartburn?

Yes
No

Do you have excessive yeast issues, or intense sugar cravings?

Yes
No

Do you regularly deal with stressful situations at work or at home?

Yes
No

At home or work do you ever experience situations that can cause anxiety or depression?

Yes
No