Gut Health Screening Questionaire

Gut Health Screening Questionaire

Screening Instructions

Please rate the severity of the following symptoms over the past week on a scale of 1 to 7, where:

1 = No discomfort at all, 2 = Minor discomfort, 3 = Mild discomfort, 4 = Moderate discomfort, 5 = Moderately severe discomfort, 6 = Severe discomfort, 7 = Very severe discomfort

Reflux Syndrome:

1. Heartburn (Unpleasant burning sensation in your chest)*

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2. Acid reflux (stomach acid flows backward into the throat, which can cause discomfort or a sour or bitter taste in the mouth).*

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Abdominal Pain:

3. Stomach pain (Pain or discomfort in your upper abdomen or pit of your stomach)*

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4. Hunger pains (A hollow feeling in the stomach associated with the need to eat between meals).*

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5. Nausea (A feeling of wanting to throw up or vomit)*

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Indigestion Syndrome:

6. Borborygmus (Stomach rumbling refers to vibrations or noise in the stomach)*

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7. Abdominal distension ("swollen belly" or "feeling bloated”).*

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8. Eructation (belching or burping which refers to bringing up air or gas from the stomach through the mouth)*

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9. Flatulence/Passing Gas (Refers to the need to release air or gas from the bowel i.e. anus often associated with relieving a bloated feeling).*

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Diarrhoea Syndrome:

10. Increased passage of stools (Too frequent bowel emptying/stooling)*

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11. Loose stools*

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12. Urgent need for defaecation (often feeling you are not in full control)*

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Constipation Syndrome:

13. Decreased frequency in passage of stools*

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14. Hard stools*

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15. Feeling of incomplete evacuation (still feel the need to pass more stool despite having pushed yourself to do so).*

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Additional Questions:

16. Are you between 18 and 65 years of age?*

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17. Have you been diagnosed with any of the following conditions?*

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18. Are you willing to take a daily supplement capsule for 8 weeks?*

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19. Are you able to use a smartphone app to complete questionnaires about your digestive health?*

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20. Are you pregnant or breastfeeding? (For female participants)*

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21. Are you Immunocompromised? i.e. Had an Organ transplant, Cancer patients, patients with immunodeficiency disorders etc.*

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22. Where did you hear about the study?

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If other, please provide details

Contact Name*

Contact Email*

Contact Phone Number*

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