First Name
Last Name
Date of Birth
Phone Number
Email Address
State of Residence
How did you hear about the Gut Reset Program?
Main digestive concerns BloatingConstipationDiarrheaGasRefluxPain
Duration of symptoms
Diagnosed GI conditions IBSGERDSIBO
Have you had a colonoscopy? YesNo
Have you had an EGD? YesNo
Date of most recent colonoscopy/EGD
Have you seen a gastroenterologist? YesNo
Was your GI workup normal/reassuring? YesNo
Currently taking acid reflux medications? YesNo
Do you use laxatives or stool softeners? YesNo
List GI medications or supplements
Upload medication list
Frequency of bowel movements Multiple times per dayOnce dailyEvery other day2–3 times per weekLess than 3 times per week
Stool consistency Hard but formedNormalSoftLoose
Presence of the Following Mucus in stoolBlood in stoolBlack or tarry stoolNone of the above
When symptoms worsen After mealsIn the morningAt nightDuring stressDuring travel
Foods that worsen symptoms
Unintentional weight loss? YesNo
Fevers, night sweats, fatigue Persistent feversNight sweatsOngoingNone of the above
Anemia or low blood counts YesNoNot Sure
Current eating pattern Standard / Mixed dietVegetarianVeganPescatarianPaleoLow-FODMAP
Food groups avoided DairyFried foodsRed meatSpicy foodsHigh-fat foodsNone
Exercise frequency Daily3–5 times per week1–2 times per week
Top 3 goals for the Gut Reset program
Insurance or self-pay InsuranceSelf-pay
High-deductible plan? YesNoNot Sure
Insurance company name
Member ID / Policy number
Consent to participate Option 1Option 2Option 3
Best time to reach you Morning (8am–12pm)Morning (8am–12pm)Afternoon (12pm–4pm)Anytime
Preferred method of contact EmailPhone callText messagePatient portal (if applicable)
Additional notes
945 Stockton Drive,Ste #6100 Allen, TX 75013
Phone: 972-390-7667
Fax: 972-390-1557
