07732 876 746
Wilmslow, Cheshire & Central Manchester
Date of birth
Please briefly describe your symptoms including when you noticed the onset.
Have any of the following tests been carried out in relation to this issue?
Stool testCoeliacSIBO breath testEndoscopyColonoscopy
How many courses of antibiotics have you had in the past 18 months?
Which of the following have you been diagnosed with?
CoelicSIBOUlcerative ColitisH PyloriMicroscopic ColitisDiverticulitisCrohn'sThyroid diseaseEndometriosis
How many bowel movements do you have per day?
Less than 1123More than 3
Which of the follow apply to you?
Belching or gas within 1 hr. of a mealHeartburn or acid refluxBloating shortly after eatingBad breath (halitosis)Sense of excess fullness after mealsFeel better if you don’t eatAnemia unresponsive to ironStomach pains or crampsChronic diarrheaDiarrhea shortly after mealsUndigested food in stoolStomach pains worse with foodStomach pains better with food
With 10 being the most severe how bad are your symptoms currently?
How would you describe your current diet?
If 'other' please specify
Which foods (if known) trigger your symptoms?
Are there any other foods that you notice are an issue?
Which of the following medication have you taken in the last month?
AntacidsAntidepressantsAntifungalsAspirin / IbuprofenBeta blockersChemotherapyLaxativePPIs (ie Omeprazole)Thyroid Medication
Are you currently being treated for any other diagnosed condition?
Is there anything else you would like to mention?