Gut Functioning Assessment

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)

Name

Briefly describe the history of your symptoms and whether they have coincided with anything else happening in your life.

Abdominal pain

Any kind of pain in your gut. Please tell me the frequency (how many days out of 7) and the severity.

Abdominal Pain Frequency

Abdominal Pain Severity

Heartburn

Burning/discomfort behind the breastbone. Please tell me the frequency and the severity.

Heartburn Frequency

Heartburn Severity

Acid Reflux

Taste of sour fluid in your mouth. Please tell me the frequency and the severity.

Acid Reflux Frequency

Acid Reflux Severity

Nausea

Feeling sick. Please tell me the frequency and the severity.

Nausea Frequency

Nausea Severity

Abdominal Noises / Gurgling

Please tell me the frequency and the severity.

Abdominal Noises Frequency

Abdominal Noises Severity

Abdominal Bloating

Feeling of swelling in the abdomen (other than after a large meal). Please tell me the frequency and the severity.

Abdominal Bloating Frequency

Abdominal Bloating Severity

Abdominal Distension

Belly sticking out / “looking pregnant”. Please tell me the frequency and the severity.

Abdominal Distension Frequency

Abdominal Distension Severity

Belching

Bringing up gas through your mouth. Please tell me the frequency and the severity.

Belching Frequency

Belching Severity

Excess Flatulence

Releasing gas more than 20 times a day. Please tell me the frequency and the severity.

Excess Flatulence Frequency

Excess Flatulence Severity

Constipation

Infrequent, hard to pass and dry faeces. Please tell me the frequency and the severity.

Constipation Frequency

Constipation Severity

Diarrhoea

Very frequent, watery or mushy faeces. Please tell me the frequency and the severity.

Diarrhoea Frequency

Diarrhoea Severity

Urgency

Needing to rush to the toilet. Please tell me the frequency and the severity.

Urgency Frequency

Urgency Severity

Incomplete Emptying

Feeling like you are not able to pass all faeces. Please tell me the frequency and the severity.

Incomplete Emptying Frequency

Incomplete Emptying Severity

Tiredness

Despite regularly getting 7 to 9 hours of sleep. Please tell me the frequency and the severity.

Tiredness Frequency

Tiredness Severity

Stools

Referring to the Bristol Stool Chart (link above), 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

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