I feel constipated often
Yes
No
I have a "tightness" in my stomach… or I feel bloated
Yes
No
I don't have much of an appetite
Yes
No
I have only one bowel movement — or none — most days
Yes
No
I'm eating junk food pretty often
Yes
No
I tend to be "low energy" lately
Yes
No
I have frequent gas, or foul gas, after eating
Yes
No
I feel full, even when I eat small amounts of food
Yes
No
I have heartburn pretty often
Yes
No
I use medicine such as Maalox or Pepto Bismol once or twice a month
Yes
No
I use laxatives often
Yes
No
I have very dark or pungent stool
Yes
No
I sweat too much…or too little
Yes
No
I have dark yellow urine, or it has a bad smell
Yes
No
I have noticed small white lines in my stool
Yes
No
I have the feeling that "something isn't right" in my digestive tract... or I'm not making enough progress trying to deal with my concerns using other methods
Yes
No
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