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The Web site for Aria - Jefferson Health, its contents and programs, is provided for informational and educational purposes only and is not intended as medical advice nor is it intended to create any physician-patient relationship. Please remember that this information should not substitute for a visit or a consultation with a health care provider. The views or opinions expressed in the resources provided do not necessarily reflect those of Aria - Jefferson Health or their staffs. By using this Web site, you accept these terms of use. Please read our privacy statement and our HIPAA Information.

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

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