Gut Functioning Assessment

Client Assessment Form

Thank you for taking time to complete this assessment questionnaire.
Link to Bristol Stool Chart

Severity Scoring Key:
0 - None
1 - Mild (I had it, but it didn’t bother me)
2 - Moderate (It was affecting me quite a bit)
3 - Severe (It had a big impact on me and what I could do)
Abdominal pain    
Any kind of pain in your gut. Please tell me the frequency (how many days out of 7) and the severity.
Heartburn
Burning/discomfort behind the breastbone. Please tell me the frequency and the severity.
Acid Reflux
Taste of sour fluid in your mouth. Please tell me the frequency and the severity.
Nausea
Feeling sick. Please tell me the frequency and the severity.
Abdominal Noises / Gurgling
Please tell me the frequency and the severity.
Abdominal Bloating
Feeling of swelling in the abdomen (other than after a large meal). Please tell me the frequency and the severity.
Abdominal Distension
Belly sticking out / “looking pregnant”. Please tell me the frequency and the severity.
Belching
Bringing up gas through your mouth. Please tell me the frequency and the severity.
Excess Flatulence
Releasing gas more than 20 times a day. Please tell me the frequency and the severity.
Constipation
Infrequent, hard to pass and dry faeces. Please tell me the frequency and the severity.
Diarrhoea
Very frequent, watery or mushy faeces. Please tell me the frequency and the severity.
Urgency
Needing to rush to the toilet. Please tell me the frequency and the severity.
Incomplete Emptying
Feeling like you are not able to pass all faeces. Please tell me the frequency and the severity.
Tiredness
Despite regularly getting 7 to 9 hours of sleep. Please tell me the frequency and the severity.
Stools
Referring to the Bristol Stool Chart, please describe the types of stools that you tend to have and the frequency of each type.
Bowel patterns
Please describe the time of day that you usually open your bowels and whether you have any associated symptoms, e.g. pain, discomfort, straining etc.
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