5R GI Restoration Program

Digestive Symptoms Assessment

Answer each question honestly to receive personalized nutritional support suggestions based on your unique GI symptom pattern.

Point values vary by question — select the option that best describes your experience

Part 1 — Occasional Stomach-Related Symptoms

With or without meals

pts

1.With or without meals, how often do you experience stomach spasms or cramps?

2.With or without meals, do strong emotions ever cause stomach pain/ache or other digestive-related discomfort?

3.With or without meals, do you ever feel a burning sensation in your stomach?

4.Do you notice that certain foods (e.g., spicy or acidic foods, coffee, citrus) cause burning or aching anywhere in your stomach or upper digestive tract?

5.Do you ever experience nausea with meals?

Part 1 Score0

Part 2 — Recurring Stomach-Related Symptoms

During or shortly after meals

pts

1.Bad taste in the mouth (heartburn)

2.Burping and belching

3.Bloating or fullness in the upper digestive tract (e.g., stomach, esophagus, diaphragm)

4.Lack of appetite

5.Food "repeats" (food comes back up)

Part 2 Score0

Part 3 — Other Gastrointestinal Symptoms

Chronic, lower bowel, and post-meal symptoms (1–4 hrs after meals)

pts

1.Have you experienced chronic intestinal or lower bowel discomfort (seemingly unrelated to meals) for more than 6 months?

2.Do you have autoimmune issues?

3.Lower abdominal bloating, cramping, and/or gas (1–4 hours after meals)

4.Lack of appetite (1–4 hours after meals)

5.Strong stool odor (1–4 hours after meals)

6.Gas and bloating with fatty foods (1–4 hours after meals)

7.Undigested food particles in stool (1–4 hours after meals)

8.Fatty stool or mucus in stool (1–4 hours after meals)

9.Loose stools or diarrhea (1–4 hours after meals)

Part 3 Score0

19 questions remaining