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How it works
Natural Supplements
FAQ
Contact Us

Upper Gut Questionnaire

Home » Upper Gut Questionnaire

Upper Gut Questionnaire

Step 1 of 7

14%

SIBO Questionnaire

Do you have SIBO?

There are a number of key symptoms that can help determine if SIBO (small intestinal bacterial overgrowth) is a contributing factor to your IBS.

Take a questionnaire below to find out!

Add up the score of each question to get a final total.

1. In the last 3 months, how often did you have burping after meals?(Required)

(0) Never or rarely

(1) Sometimes – About 25% of the time

(2) Often – About 50% of the time

(3) Most of the time – About 75% of the time

(4) Always – 100% of the time

2. In the last 3 months, did you have nausea or nausea with belching?(Required)

Yes

No

3. In the last 3 months, did taking fiber worsen your symptoms?(Required)

Yes

No

4. Did your symptom of chronic gut complaints develop after taking opiates?(Required)

Yes

No

5. Have you ever been told you have; (1 point for each yes answer)

Chronic vitamin B12 deficiency anemia

Chronic iron deficiency anemia

Chronic low ferritin with no apparent cause

Chronic vitamin D deficiency

6. In the last 3 months, have you been told you have; (1 point for each yes answer)

Acne Rosacea

Autism

Celiac disease (CD) or gluten sensitivity

Chronic fatigue syndrome

Diabetes type I or II

Diverticulitis

Fibromyalgia

Food sensitivities

H.pylori infection

Heartburn / Reflux / GERD

Hypothyroidism

IBD (Crohn’s or ulcerative colitis)

IBS

Intestinal cystitis

Lactose intolerance

Leaky gut or intestinal permeability

Liver cirrhosis

NASH (non-alcoholic steatohepatitis) or fatty liver

Restless leg syndrome

Scleroderma or lupus

Skin issues: eczema, atopic dermatitis, psoriasis

7. In the last 3 months, have you experienced the following symptoms: (1 point for each yes answer)

Brain fog, memory problems

Breathing issues, problems or difficulties

Chronic allergies

Chronic sinus infections

Headaches

Joint pain

Yeast or fungal infections

8. Do you have Celiac disease and maintain a gluten free diet, but still feel unwell?(Required)

Yes

No

9. Do you have gluten-sensitivity and maintain a gluten free diet, but still feel unwell?(Required)

Yes

No

10. In the last 3 months, on a CT scan, they couldn't see my pancreas due to a gas bubble(Required)

Yes

No

11. In the last 3 months, how often have you noticed fat in your stool? (Steatorrhea)(Required)

(0) Never or rarely

(1) Sometimes – About 25% of the time

(2) Often – About 50% of the time

(3) Most of the time – About 75% of the time

(4) Always – 100% of the time

12. Did any of your gut symptoms improve during antibiotic use?(Required)

Yes

No

13. In the last 3 months, did any of your gut symptoms worsen with probiotic use that contained prebiotics (FOS, arabinogalactan)(Required)

Yes

No

14. Did your symptoms begin after travel or food poisoning?(Required)

Yes

No

15. How often do you include starches/grains/carbs in your meals and snacks (bread, baked goods, pasta, rice, etc.)(Required)

(0) Never or rarely

(1) Sometimes – About 25% of the time

(2) Often – About 50% of the time

(3) Most of the time – About 75% of the time

(4) Always – 100% of the time

16. In the last 3 months, how often did your symptoms worsen from eating grains/carbs/starches?(Required)

(0) Never or rarely

(1) Sometimes – About 25% of the time

(2) Often – About 50% of the time

(3) Most of the time – About 75% of the time

(4) Always – 100% of the time

17. I tend to graze/nibble throughout the day rather than eat 3 square meals(Required)

Yes

No

18. Were you delivered by cesarean (C-section)(Required)

Yes

No

19. Were you breast fed as a baby?(Required)

Yes

No

20. Were you given antibiotics regularly as a child (ear infection, tonsillitis, strep throat, etc.)?(Required)

Yes

No

21. Have you taken antibiotics often or regularly as an adult?(Required)

Yes

No

22. Have you taken oral birth control pills regularly as an adult?(Required)

Yes

No

23. Have you experienced periods of severe stress or shock?(Required)

Yes

No

Name(Required)

First Last

Phone(Required)

Email(Required)

Date of Birth(Required)

MM slash DD slash YYYY

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