Digestive & Microbiome Optimization Activation Form
Unique ID
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Date Signed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What is the main reason you are completing this form?
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Bloating
Constipation
Diarrhea
Reflux/heartburn
Food sensitivities
Abdominal pain
Autoimmune/inflammatory concerns
Weight/metabolic issues
Fatigue/brain fog
Skin issues
General gut optimization
Other
Medications, Supplements, Testing & Review
What are your top 3 goals for optimization?
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Better digestion
Less bloating
More regular bowel movements
Better energy
Improved skin
Less inflammation
Weight/fat loss support
Better immune function
Improved mood/mental clarity
Better food tolerance
Other
Have you completed any previous gut-related testing?
Stool test
SIBO breath test
Food sensitivity test
Celiac testing
Colonoscopy
Endoscopy
H. pylori test
None
Other
List all current medications.
List all current supplements, probiotics, digestive enzymes, fiber products, or gut-health products.
Digestive Symptoms
How often do you experience bloating?
Rarely
A few times per month
Weekly
Several times per week
Daily
When does bloating usually happen?
Upon waking
After meals
End of day
Randomly
Not applicable
Do you have abdominal pain or cramping?
Yes
No
Do you have excessive gas or belching?
Yes
No
Do you have reflux, heartburn, or indigestion?
Yes
No
Do you have nausea or early fullness after eating?
Yes
No
Does food feel heavy in your stomach after meals?
Yes
No
Do you have urgent bowel movements?
Yes
No
Do you feel fully emptied after a bowel movement?
Yes
No
How many bowel movements do you typically have per day or week?
Please specify whether your count is per day or per week when entering your answer.
Which Bristol Stool Chart type do you usually have?
Type 1: Hard separate lumps
Type 2: Lumpy sausage
Type 3: Cracked sausage
Type 4: Smooth soft sausage
Type 5: Soft blobs
Type 6: Mushy stool
Type 7: Watery stool
Varies
Have you noticed mucus, blood, black stool, or oily/floating stool?
No
Mucus
Blood
Black/tarry stool
Oily/floating stool
Unsure
Food Triggers & Diet
Do certain foods trigger your symptoms?
Yes
No
Which foods seem to trigger symptoms?
Dairy
Gluten/wheat
Eggs
Soy
Corn
Sugar
Fried foods
Spicy foods
High-fiber foods
Beans/legumes
Onions/garlic
Alcohol
Artificial sweeteners
Not sure
Other
Do symptoms worsen after high-carb or sugary meals?
Yes
No
Do symptoms worsen after high-fat meals?
Yes
No
How many servings of vegetables do you eat per day?
How much water do you drink daily? Please state the amount in US fluid ounces (fl oz) or liters (L) and indicate which unit you used.
How often do you eat fermented foods?
Never
Rarely
Weekly
Several times per week
Daily
Do you currently follow a specific diet?
Standard diet
High protein
Low carb
Keto
Mediterranean
Vegan/vegetarian
Gluten-free
Dairy-free
Low FODMAP
Carnivore
Gut History & Medical Background
Have you ever been diagnosed with any of the following?
IBS
IBD/Crohn's/ulcerative colitis
GERD
Gastritis
Celiac disease
SIBO
H. pylori
Diverticulosis/diverticulitis
Gallbladder disease or gallbladder removal
Pancreatic insufficiency
Fatty liver
Autoimmune disease
None
Other
Have you had any GI procedures or surgeries?
Colonoscopy
Endoscopy
Gallbladder removal
Appendix removal
Bariatric surgery
Bowel surgery
None
Other
Have you taken antibiotics in the past 12 months?
Yes
No
Have you had food poisoning, stomach infection, parasite exposure, or traveler’s diarrhea?
Yes
No
Have you been treated for H. pylori, SIBO, candida, parasites, or dysbiosis?
Yes
No
Do you have a family history of colon cancer, IBD, celiac disease, or autoimmune disease?
Yes
No
Systemic Symptoms & Red Flags
Do you experience fatigue, brain fog, or trouble concentrating?
Yes
No
Do you experience anxiety, low mood, irritability, or mood changes related to meals or digestion?
Yes
No
Do you have skin issues such as acne, eczema, psoriasis, rashes, or flushing?
Yes
No
Do you have joint pain, body aches, or unexplained inflammation?
Yes
No
Have you had any unintended weight loss?
Yes
No
Do you have difficulty swallowing?
Yes
No
Have you had a fever recently?
Yes
No
Have you had persistent vomiting?
Yes
No
Do you have GI symptoms that wake you from sleep?
Yes
No
Are you pregnant or breastfeeding?
Pregnant
Breastfeeding
Neither applicable
Do you have any allergies or sensitivities?
Food allergies
Medication allergies
Environmental allergies
Chemical sensitivities
Supplement sensitivities
None
Other
Other
How long have you had your current stool frequency pattern?
Do you experience frequent infections, allergies, sinus congestion, or immune sensitivity?
Yes
No
Medical Review & Consent
Are you willing to complete recommended lab, stool, breath, or microbiome testing if clinically appropriate?
Yes
No
Are you willing to make nutrition, lifestyle, and supplement changes for at least 8–12 weeks?
Yes
No
What is the biggest challenge when trying to improve gut health?
Consistency
Meal planning
Cost
Stress
Travel/work schedule
Conflicting advice
Food restrictions
Not knowing where to start
Other
Is there anything else we should know about your digestion, symptoms, or goals?
I understand that this form is part of medical care and will be reviewed by the provider/care team. Any recommendations, interpretations, or outputs require provider review, and I will not make medication changes without guidance from the prescribing clinician. I understand that urgent symptoms such as blood in stool, black/tarry stool, unexplained weight loss, severe abdominal pain, persistent vomiting or dehydration, fever, difficulty swallowing, nocturnal GI symptoms, jaundice, pregnancy or breastfeeding, GI cancer/IBD/celiac family history, prior surgeries, antibiotics, and allergies/sensitivities require prompt medical evaluation.
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Yes, I understand and agree.
Submit
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