Digestive Screening

Digestive Screening

Please note that all fields followed by an asterisk must be filled in.
Gain Weight
Lose Weight
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Dog
Cat
Bird
Turtle
Other Pet
Yes
No
Ulcers or Gastritis
Gall Stones or Gallbladder Issues
Liver Issues, including elevated or depressed Liver Enzymes
GERD/Reflux
Pancreatitis
Celiac Disease
IBS/IBD/Colitis
OTC Antacids
OTC Laxatives or Fiber
Other Digestive Aids
Eating or drinking relieves it
Eating or drinking makes it worse
My stomach starts hurting or I get bloated immediately after or while eating or drinking
My stomach starts burning or I get bloated 30 mins to several hours after I eat or drink
Certain foods seem to make this worse
Small, round or hard
Thin - pencil like
Pasty or fatty
Loose
Very foul
It's not nice, but not really offensive
Very offensive and embarrassing
Yes
No
Yes
No
Yes
No
Yes
No

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