Hi, we know we are asking quite a few questions but it will help us understand your case better and provide the best treatment. Step 1 of 5 20% Help us understand your symptoms better to diagnose properly with the following questionsPlease enter your Phone Number(Required)Q. What is your gender?(Required) Male Female None of the above Q. Do you experience any of the following?(Required) Burning in the chest after meals? Bowel Urgency Excess gas or flatulence Mucous in stools Throat discomfort Acidic Taste in mouth Feeling of regurgitation Trouble Swallowing Food Cough Hoarse Voice None of the above Other Q. Any trigger foods that you suspect?(Required) Wheat Milk Sugar Pulses Acidic Foods Spicy Foods Alcohol None of the above Others Q. How often do your gastro symptoms affect your sleep?(Required) Every night Few nights a week Occasionally Never Q. Are you usually satisfied with your bowel movements?(Required) Yes No Q. When did you first notice your symptoms?(Required) Within the last month A few months ago 6-12 months ago 1-5 Years ago 5-10 years ago More than 10 years ago Q. Please share any other details about the digestive issues you are currently facing?(Required)Q. Which of the following symptoms are you hoping to address?(Required) Abdominal Pain Constipation Diarrhoea Irregular or Altered Bowel Habit Bloating or excessive Gas Nausea or vomiting Heartburn Regurgitation of food or liquid None of the above Others Q. In the last 6 months have you experienced any of the following symptoms?(Required) Blood in stool Unintentional weight loss > 5kgs Vomiting more than once a week Black-coloured stool None of the above Please help us understand the treatments that you have tired in the past with the following questionsQ. What prior gut-related treatments have you tried?(Required) Over-the-counter medicines for diarrhoea Peppermint Oil Probiotics Antibiotics Antidepressants Antispasmodic medicines Other prescription Gastro Drugs Supplements Dietary Changes (Low FODMAP, Keto etc) Acupuncture Diaphragmatic Breathing Exercises Enemas or Suppositories None of the above Others Q. Which medications in the past were helpful in giving relief?(Required) Q. Is the symptom better or worse after eating?(Required) Better Worse No Change Q. Have you used any of this medication in the past?(Required) Over-the-counter antacids like Digene, Gelusil Acid Reducing agents, histamine blocking types like rantac Acid Reducing agents, proton pump inhibitors like Pantoprazole, Omeprazole None of the above Others Q. Have you had any of these tests done to evaluate your GI symptoms?(Required) Blood Work Stool Test Endoscopy Breath Testing for SIBO Breath Testing for H.Pylori Colonoscopy Abdominal Imaging None of the above Others Q. Have you ever taken any of these medications in the past?(Required) Fibre Supplements Over the counter laxatives Enemas Probiotics None of the above Others Q. Have you ever been diagnosed with any of the following GI conditions in the past?(Required) Irritable Bowel Syndrome Small Intestinal Bacterial Growth Heartburn/Acid Reflux/GERD Gastritis or Peptic Ulcer None of the above Others Q. What have you tried in the past?(Required) Supplements Prescription Medication Dietary Changes (Low FODMAP, Keto etc) Acupuncture Diaphragmatic Breathing Exercises None of the above Others It is important to understand your generic health outside of GI. Please answer the following questionsQ. Do you have any allergies?(Required) Q. What medications are you currently taking?(Required) Q. Do you have any of these following symptoms outside GI Issue?(Required) Rash Joint Pain Mouth Sores Eye Pain None of the above Q. In addition to your GI symptoms, do you have any other medical conditions?(Required) High Blood Pressure High Cholesterol Diabetes Heart Disease Thyroid Problems Type 1 or Type 2 Diabetes Hyper/Hypo Tension Stroke Arthritis PCOS/PCOD Hypo/Hyper Thyroidism Asthma or other Respiratory Problems None of the above Others Q. What is your weight?(Required) Q. What is your height?(Required) Help us understand your lifestyle as it hugely impacts the gut. Please answer the following questionsQ. Do you have a known history of disordered eating?(Required) Q. What is your approach to following a new diet?(Required) I take my time in researching a new diet or habit and then try it out I TEND TO BUDDY UP WITH A FRIEND OR FAMILY MEMBER TO MAKE A NEW HABIT I start off strong but then lose the motivation I need to sit with an idea before making the mind to invest in it I need someone to handhold me I struggle to find time for new habits Q. When often do you feel rested when you wake up?(Required) 1-2 times a week 3-4 times a week 5-7 times a week Q. What’s one non-healthy habit of yours that you find the toughest to stop?(Required) Q. What time do you eat dinner? Q. What time do you eat breakfast?(Required) Q. What time do you eat lunch?(Required) Q. Do you currently smoke?(Required) Yes No Q. Did you smoke in the past?(Required) Yes No Q. What time do you usually go to bed?(Required) Do you drink alcohol? Daily Couple of times a week Occasionally Rarely Q. What occupation are you in?(Required) Corporate Office (Like Infosys, Bain, Deloitte, Wipro, Shell, Flipkart, Reliance etc) Public Sector (PSUs, Police etc) Startups Office(Cred, Byjus etc) Self Employed Home Maker Field Work Other Q. What is your workout type?(Required) Walking Gym Sports Yoga Q. How many times do you workout in a week? (Inclusive of sports, walking, gym and others)(Required) 1 2 3 4 5 6 7 Q. How is your menstrual cycle?(Required) Regular Irregular Menopause Not Applicable Q. What is your food preference?(Required) Veg Non-Veg Vegan Gluten Free Eggetarian Other Q. How many meals are outside food?(Required) More than 4 a week 1-4 meals per week 1-2 meals in 2 weeks 1-2 meals in a month Other Q. What is your water intake?(Required) <1l/day 1-1.5 L/day 1.5-2.5 L/day >2.5 L/day Q. What are your Tea and Coffee habits?(Required) More than 2 times in a day 1-2 times daily Few times a week Rarely Never Q. How many hours do you sleep?(Required) <4 hours 4-6 hours >6 hours Q. How is your sleep quality?(Required) Good Bad Broken Sleep What is your goal? Mindfulness and gut go hand in hand. Please answer the following questionsQ. How often do you feel supported by your family while talking about GI Symptoms?(Required) Always Usually Sometimes Not Usually Never Q. Have you experienced and or been treated for any of the following mental health concerns?(Required) Depression Anxiety None Other Q. How often do you think about your gastro symptoms?(Required) All the time Most of the time Some of the time Rarely Q. How would you rate your stress levels?(Required) Below Average Average Above Average High
