Gastrointestinal Assessment Form

MM slash DD slash YYYY

Questionnaire Scale

0= Never; 1= Occasionally; 2= Sometimes; 3= Frequently; 4= Always.

Section 1 – Swallowing

Difficulty swallowing supplements
Difficulty swallowing large bites of food
A need to chew food excessively before swallowing
Difficulty producing saliva when chewing
Dry mouth

Section 2 – Intestinal Motility

Inconsistent regularity in bowel movements
Bowel straining with bowel movements
Need to use stool softeners, laxatives, or enemas

Section 3 – Digestion of Protein in the Stomach

Difficulty digesting high protein foods (meats, eggs, nuts, etc.)
Excessive belching and burping
Offensive breath
Sense of fullness during and after meals
Bloating within the first 30-60 minutes after meals

Section 4 – Stomach Lining Irritation or Ulcer

Stomach pain, burning, or aching 1-4 hours after eating
Need to use antacids after meals
Heartburn when lying down or bending forward
Heartburn after spicy foods, alcohol, citrus, or caffeine

Section 5 – Difficulty Digesting Fibers and Starches by Pancreatic Enzymes

Difficulty digesting fiber and starches (vegetables, fruits beans, rice, etc.)
Bloating within the first 1-2 hours after meals
Pain and tenderness on the left side of the rib cage after meals

Section 6 – Difficulty Digesting Fats from Gallbladder Release of Bile

Abdominal bloating and distress after fatty, oily, or fried foods
Burping, fishy taste after taking fish oils or eating fish
Pain between shoulder blades or right rib cage after eating fatty foods
Nausea or sensations of vomiting after meals

Section 7 – Evaluation of Bowel Movement and Stool

Undigested food found in stool
Mucus found in stool
Floating stool
Excessively foul smelling stool
Clay colored stool
Blood in stool or black colored stool
Blood on toilet paper after wiping

Section 8 – Intestinal Permeability/Leaky Gut

Increasing frequency of reactions to foods
Inflammation, swelling and pain throughout body
Unpredictable bloating and swelling

Section 9 – Small-Intestine Bacteria Overgrowth

Abdominal dissention after any consumption of fiber, starches, and sugars
Abdominal distention with probiotics or natural supplements

Section 10 – Malabsorption

Do you feel like you are not absorbing your nutrients?
Losing weight and have difficulty gaining weight
Losing muscle mass
Bruise easily or have bleeding gums
Muscle spasms
Swelling of the tongue
Deep muscle or bone pain