GI Health Appraisal Questionnaire

GI Health Appraisal Questionnaire

Directions

This questionnaire asks you to assess how you have been feeling during the last four months. This information will help you keep track of how your physical, mental and emotional states respond to changes you make in your eating habits, priorities, supplement program, social and family life, level of physical activity and time spent on personal growth.

All information is held in strict confidence. Take all the time you need to complete this questionnaire.

For each question, select the number that best describes your symptoms:
0 = No or Rarely
Symptom never experienced or insignificant.
1 = Occasionally
Symptom comes and goes.
4 = Often
Symptom occurs 2-3 times per week.
8 = Frequently
Symptom occurs 4 or more times per week or regularly.
SECTION A
1. Indigestion, food repeats on you after you eat
2. Excessive burping, belching and/or bloating following meals
3. Stomach spasms and cramping during or after eating
4. A sensation that food just sits in your stomach creating uncomfortable fullness, pressure and bloating during or after a meal
5. Bad taste in your mouth
6. Small amounts of food fill you up immediately
7. Skip meals or eat erratically because you have no appetite
Total Points: 0
SECTION B
1. Strong emotions, or the thought or smell of food aggravates your stomach or makes it hurt
2. Feel hungry an hour or two after eating a good-sized meal
3. Stomach pain, burning and/or aching over a period of 1-4 hours after eating
4. Stomach pain, burning and/or aching relieved by eating food; drinking carbonated beverages, cream or milk; or taking antacids
5. Burning sensation in the lower part of your chest, especially when lying down or bending forward
6. Digestive problems that subside with rest and relaxation
7. Eating spicy and fatty (fried) foods, chocolate, coffee, alcohol, citrus or hot peppers causes your stomach to burn or ache
8. Feel a sense of nausea when you eat
9. Difficulty or pain when swallowing food or beverage
Total Points: 0
SECTION C
1. When massaging under your rib cage on your left side, there is pain, tenderness or soreness
2. Indigestion, fullness or tension in your abdomen is delayed, occurring 2-4 hours after eating a meal
3. Lower abdominal discomfort is relieved with the passage of gas or with a bowel movement
4. Specific foods/beverages aggravate indigestion
5. The consistency or smell of your stool changes (e.g., from narrow to loose) within the course of a day
6. Stool odor is embarrassing
7. Undigested food in your stool
8. Three or more large bowel movements daily
9. Diarrhea (frequent loose, watery stool)
10. Bowel movement shortly after eating (within 1 hour)
Total Points: 0
SECTION D
1. Discomfort, pain or cramps in your colon (lower abdominal area)
2. Emotional stress and/or eating raw fruits and vegetables causes abdominal bloating, pain, cramps or gas
3. Generally constipated (or straining during bowel movements)
4. Stool is small, hard and dry
5. Pass mucus in your stool
6. Alternate between constipation and diarrhea
7. Rectal pain, itching or cramping
8. No urge to have a bowel movement
9. An almost continual need to have a bowel movement
Total Points: 0
Grand Total: 0