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Gastrointestinal System Form
Gastrointestinal System Form
Name Surname
What is the shape of your stool?
Usually floats on water
Thin and long
Diarrhea
In small and hard pieces
Loose but not like full diarrhea
Solid, I can strain
Soft and tight structure
It ranges from solid to loose.
Do you often experience gas problems during the day?
Yes
No
At what time of day do you experience gas problems more often?
Morning Hours (09:00-11:00)
Lunch Hours (12:00-14:00)
Evening Hours (17:00-21:00)
Is your gas smelling too intense?
Yes
No
Do you experience bad breath?
Yes
No
Do you experience bloating or burping right after meals?
Yes
No
Do you have a feeling of fullness (swelling/full satiety) or nausea after eating?
Yes
No
If your answer is YES, does it happen two to four hours after a meal or just after?
After 2 to 4 hours
Shortly after
Do you have a problem grinding your teeth at night?
Yes
No
Do you have undigested food in your stool? What foods, if any, do you see?
Do you have a feeling of fullness (swelling/full satiety) or nausea after eating?
Yes
No
If your answer is YES, two to four hours after a meal or just after?
After 2 to 4 hours
Shortly after
Have you ever been diagnosed with Iron deficiency or vitamin B12 deficiency?
Yes
No
Do you suffer from chronic intestinal infections, such as parasitic infections?
Yes
No
Do you often have itching in your rectum (last part of the large intestine) and/or nose?
Yes
No
Have you ever had an enema or colon cleansing, or have you used any medication to make your stool ?
Yes
No
Do you follow any of the special diets or nutrition programs such as a vegetarian or ketogenic diet?
You have one or more of the following foods, cooked or raw; Does it create an undesirable condition such as gas, heartburn, diarrhea, constipation, pain, drowsiness, weakness, dizziness, skin, runny nose?
Brussels sprouts
Coconut
Pear
Garlic
Cabbage
Apple
Peach
Onion
Broccoli
Watermelon
Nectarine
Avocado
Cauliflower
Apricot
Dried fruits
raw vegetables
Cooked Legumes
You have one or more of the following foods; Does it create an undesirable condition such as gas, heartburn, pain, diarrhea, constipation, drowsiness, weakness, dizziness, skin, runny nose?
wait meat
Yogurt
Wine
Tomatoes
Salami/Sausage/Sausage
Ayran
Beer
Spinach
Fish
Cheese
Pickle
Banana
Kefir
Vinegar
Aubergine
Strawberry
Orange
Lemon
Citrus
Are there any foods that you can't stand and consume too much? If so, what?
How many meals do you eat per day?
1 time
2 time
3 time
Does skipping a meal greatly affect you?
Tick the ones that fit your eating habits.
I eat fast.
I eat too much.
I eat late at night.
I don't like healthy food.
I do not eat healthy food prepared at home
My snack place.
There are those who do not like healthy food in the family
I travel often.
I skip meals
I eat a lot when I'm stressed.
I like to eat.
I drink water between meals
I eat out of necessity.
I'm not good with food
I eat less when I'm stressed.
I don't mind cooking
I travel often.
I eat out more than half of my meals
Write down what you ate/how much you ate during the weekday and the times.
Breakfast:
Lunch:
Evening meal:
Snack:
Drinks:
Write down what you ate/how much you ate during the weekend and the times.
Breakfast:
Lunch:
Evening meal:
Snack:
Drinks:
How many times do you consume the foods listed below in a week?
Fruit (not squeezed):
Vegetables (Except White Potatoes):
Legumes (beans, peas, etc.):
Milk/types:
Soda (normal or diet):
Desserts (Candy, cookies, cake, ice cream, etc.):
Meat:
Nuts:
Fish:
Oils:
Sweeteners:
How often do you go to the defacate?
Daily 1
Daily 2
Weekly 2
Weekly 3
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