Gut health Questionnaire Click Here to complete questionnaire Gut Health Questionnaire Coupon Code Enter Promotional Code if Applicable Name * First Name Last Name Date of Birth * MM DD YYYY Gender * Select Male Female Primary Reason for Checking Your Gut Health * Choose all that apply Performance Muscle Growth Immune Support Mental Performance Weight Loss Weight Gain Energy Gastric protection and repair In your own words tell us what your complaint is * example: "I am tired all the time", or "I feel bloated all the time" Email * Mobile Phone * (###) ### #### Home Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Height (Feet) * Select 1 2 3 4 5 6 Height (Inches) * Select 1 2 3 4 5 6 7 8 9 10 11 Weight * In pounds Do you experience or have you been diagnosed with any of the following? * Check all that apply Diarrhea Constipation Gas Bloating/distention Abdominal discomfort/Cramping Indigestion/acid reflux Allergies/asthma Cardiovascular disease Mood disorders (i.e., depression) Autoimmune disease Diabetes Nutritional deficiencies Dyspepsia Irritable Bowel Syndrome (IBS) Inflammatory Bowel Disease (IBD) Celiac Disease Fibromyalgia Rosacea Parkinson’s Disease Obesity Intestinal motility disorders Chronic pancreatitis Gastroenteritis Immunocompromised Decreased bacteriostatic digestive secretions (HCl, pancreatic enzymes, bile acids) such as with PPI use Ileocecal valve dysfunction Atopic dermatitis/ eczema Joint aches Do you take any of the following types of supplements or medications? * Check all that apply Antacids? (Examples: Aluminum hydroxide gel. Calcium carbonate (Alka-Seltzer, Tums) Magnesium hydroxide (Milk of Magnesia) Gaviscon, Gelusil, Maalox, Mylanta, Rolaids. Pepto-Bismolect...) H2 Blockers? (Examples: Famotidine (Pepcid AC, Pepcid Oral, Zantac 360), Cimetidine (Tagamet, Tagamet HB), Nizatidine Capsules (Axid AR, Axid Capsules, Nizatidine Capsules), Ranitidine (Zantac) Proton Pump Inhibitors (PPIs)? (Examples: Omeprazole (Prilosec), Esomeprazole (Nexium), Lansoprazole (Prevacid), Dexlansoprazole, Pantoprazol (Protonix), Rabeprazole) Laxatives? None How Did You Hear About Us??? * Select Personal Referral (enter name in next question) Office Sign Website Facebook Instagram Youtube Pinterest Twitter Other Social Media IFM Website Other (enter in next question) Enter name of person referring you or other Thank you for completing you questionnaire After clicking submit you will be directed to our facebook page. Please like and invite your friends! We will be reaching out to you within 24 business hours. Thank you! Please like our facebook page and share!
