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)

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

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

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

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

Please tell me the frequency and the severity.

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


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

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

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

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

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

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

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

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

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.

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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