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Gastrointestinal Conditions Risk Assessment

The following questionnaire gives a sense of the likelihood of having or developing a gastrointestinal condition.

Do you experience stomach, intestinal, or other digestive-system discomfort regularly? Yes No
Do you have GI symptoms that compromise your quality of life or your ability to participate in activities? Yes No
Do you experience pain or cramping in your abdomen? Yes No
Do you often have a feeling of being bloated or distended in your lower belly? Yes No
Do you experience nausea or vomiting regularly? Yes No
Do you often have a feeling of burning in your throat, chest, or gut? Yes No

Does such burning bother you at nighttime?

Yes No
Do you feel like you often have a sore throat, hoarse voice, or need to clear your throat? Yes No
Has there been significant change in your stool habits?  Yes No

Are your bowel movements or bowel patterns disrupted by diarrhea or constipation, or both?

Yes No
Do you have bowel movements more than three times per day or less than three times per week? Yes No
Do you sometimes experience discomfort after a bowel movement? Yes No
Do you ever notice that your stool is bloody, or often covered with mucus? Yes No

Do your digestive symptoms correspond with what you eat?

Yes No

Do your digestive symptoms correspond with your eating schedule?

Yes No

Do you make significant use of over-the-counter products for nausea, heartburn, constipation, or diarrhea?

Yes No
Do your digestive symptoms correspond with times of stress? Yes No

Do you have a lifestyle that is inactive?

Yes No
Is your diet low in fiber or high in rich foods? Yes No
Do you have an immediate family member (parent, sibling, or child) who has suffered from reflux disease, irritable bowel syndrome, or other digestive condition? Yes No


The more often you answered “Yes” to the above questions, the greater your risk for developing or already having a gastrointestinal condition.  If you answered “Yes” to questions above, consider discussing gastrointestinal conditions with one of our Women’s Center healthcare providers.

Print this page and bring it with you, filled out, to your appointment.