2211 N Buffalo Bill Ave, North Platte, NE 69101 · www.familyfirsthealthcenter.org

Digestive Health Questionnaire

This form follows food through your digestive system, from mouth to rectum. It takes about 15 minutes. Your answers stay on this device until you send the results code to our office.

How to score each symptom

Think about the past 3 months. Tap the number that fits best.

0Never or almost never

1Occasionally or mild

2Often or moderate

3Daily or severe

Your initials Today's date

For your privacy we only ask for initials. We match your results to your chart when your email arrives.

0 of 103 answered

Bowel habits

Your usual bowel movements

Bowel movements per day Or per week (if less than daily)

Usual stool type (Bristol Stool Chart) Usual stool color

Section 9

Important symptoms

Answer yes or no for each.

Section 10

Health history

Diagnoses you have had (check all that apply)

Medications you take or have taken (check all that apply)

Antibiotic courses in the past 12 months Glasses of water per day Alcoholic drinks per week Stress level, 0 (none) to 10 (severe)

Abdominal surgeries (gallbladder, appendix, bowel, bariatric, other) Last colonoscopy (year and result) When did your digestive symptoms start? Any trigger? What makes your symptoms better or worse?

Questionnaire complete

Thank you. One last step.

Send your results to our office so your provider can review them before your visit.

Send your results

Tap the button. Your email app opens with our address and your results code already filled in. Then tap Send.

Email my results to the office

On a computer and use email in your web browser? Choose your email service. It opens in a new tab with everything filled in.

Open in Gmail Open in Outlook.com Open in Yahoo Mail

If no email app opens

Tap Copy results code.
Open your email and start a new message to the address below.
Paste the code into the message, put your initials in the subject line, and send it.

ffhc.nurses@gmail.com