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IBS
IBD
Mind-Gut
Nutrition
Lifestyle

Survey

First Name

Last Name

Email Address

What Are Your Current Symptoms?

Abdominal pain

Diarrhea

Gas or bloating

Constipation

Acid reflux / Heartburn

Fatigue

Swallowing problems

Nausea / Vomiting

Weight gain or Weight loss

How Long Have You Had Your Symptoms?

Less Than 1 month

2 - 6 months

6 months or more

None

How Frequently Do You have Symptoms?

A few times a month

Once a week

Every day

None

How would you rate the severity of your symptoms?

Frequent and severe

Frequent and moderate

Frequent and mild

Occasional and severe

Occasional and moderate

Occasional and mild

None

Have You been diagnosed with any of these conditions?

Irritable Bowel Syndrome (IBS)

Heartburn/GERD

Small Intestinal Bacterial Overgrowth (SIBO)

Inflammatory Bowel Disease (IBD)

Ulcers

Celiac Disease

Diverticulitis

None of these conditions

Have you had any of these to help diagnose your symptoms?

Blood Test

Stool Test

Colonoscopy

Breath Test

CT Scan or MRI

Ultrasound

Upper Endoscopy

None of These

Would you like to make an appointment with one of our GI providers at the end of this assessment?

Yes

Yes, but not today

I am just looking for now

None

Are you currently being treated by a gastroenterologist?

Yes but I am not satisfied with my current treatment

Yes but I am looking for a more convenient solution

No I am not being treated by a gastroenterologist

None

Have you used a Telehealth service before?

Yes, For these symptoms

Yes, but for another condition

No

None

How are you currently treating your GI-related Symptoms?

Over the counter medications

Prescription medications

Diet and Lifestyle changes

None

Abdominal pain

Diarrhea

Gas or bloating

Constipation

Acid reflux / Heartburn

Fatigue

Swallowing problems

Nausea / Vomiting

Weight gain or Weight loss

Abdominal pain

Diarrhea

Gas or bloating

Constipation

Acid reflux / Heartburn

Fatigue

Swallowing problems

Nausea / Vomiting

Weight gain or Weight loss

Less Than 1 month

2 - 6 months

6 months or more

None

Time's up

Find lasting relief from digestive issues

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The opinions and testimonial comments made in Oshi Health materials are made by Oshi Health patients and are based upon their own personal experience. Individual experiences may vary.

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