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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)
Basic Info
Abdominal pain
Any kind of pain in your gut. Please tell me the frequency (how many days out of 7) and the severity.
Frequency
0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days
Severity
None
Mild
Moderate
Severe
Heartburn
Burning/discomfort behind the breastbone. Please tell me the frequency and the severity.
Frequency
0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days
Severity
None
Mild
Moderate
Severe
Acid Reflux
Taste of sour fluid in your mouth. Please tell me the frequency and the severity.
Frequency
0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days
Severity
None
Mild
Moderate
Severe
Nausea
Feeling sick. Please tell me the frequency and the severity.
Frequency
0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days
Severity
None
Mild
Moderate
Severe
Abdominal Noises / Gurgling
Please tell me the frequency and the severity.
Frequency
0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days
Severity
None
Mild
Moderate
Severe
Abdominal Bloating
Feeling of swelling in the abdomen (other than after a large meal). Please tell me the frequency and the severity.
Frequency
0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days
Severity
None
Mild
Moderate
Severe
Abdominal Distension
Belly sticking out / “looking pregnant”. Please tell me the frequency and the severity.
Frequency
0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days
Severity
None
Mild
Moderate
Severe
Belching
Bringing up gas through your mouth. Please tell me the frequency and the severity.
Frequency
0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days
Severity
None
Mild
Moderate
Severe
Excess Flatulence
Releasing gas more than 20 times a day. Please tell me the frequency and the severity.
Frequency
0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days
Severity
None
Mild
Moderate
Severe
Constipation
Infrequent, hard to pass and dry faeces. Please tell me the frequency and the severity.
Frequency
0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days
Severity
None
Mild
Moderate
Severe
Diarrhoea
Very frequent, watery or mushy faeces. Please tell me the frequency and the severity.
Frequency
0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days
Severity
None
Mild
Moderate
Severe
Urgency
Needing to rush to the toilet. Please tell me the frequency and the severity.
Frequency
0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days
Severity
None
Mild
Moderate
Severe
Incomplete Emptying
Feeling like you are not able to pass all faeces. Please tell me the frequency and the severity.
Frequency
0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days
Severity
None
Mild
Moderate
Severe
Tiredness
Despite regularly getting 7 to 9 hours of sleep. Please tell me the frequency and the severity.
Frequency
0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days
Severity
None
Mild
Moderate
Severe
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.
Stool size
Small (less than 1 egg)
Medium (1-2 eggs)
Large (more than 2 eggs)
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privacy statement
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