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Gut Health Consultation Intake

Please complete this intake upon scheduling your appointment. Your GI MAP test will not be ordered until this is submitted.

Date of birth
Gender
Female
Male

Anthropometrics

Medical History

Have you had frequent illnesses in the past requiring antibiotics?
Yes
No
Which of the following symptoms do you struggle with?

Sleep, Stress & Energy

Do you feel rested when you wake up in the mornings?
Yes
No
Sometimes

Female Health

Nutrition

Have you ever been formally diagnosed with an eating disorder?
Yes
No
Are you currently following any of the following dietary restrictions?

Occupational Health

What would you consider your current weekly exercise routine?
No current exercise routine
1-3 hours gentle exercise (walking)
3-4 hours moderate exercise (running, exercise classes, Peloton)
4-6 hours intense exercise ( crossfit, weightlifting)
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