CENTRE FOR
RESTORATIVE
MEDICINE

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gut assessment

Submitting this questionnaire is not a substitute for a medical assessment. If your symptoms are severe we recommend a consult.

Select any of the questions that apply

First Name

Last Name

Email

I regularly experience gas or bloating

Certain foods upset my stomach

I am taking medications for heart burn e.g. PPI

My weight has changed for no obvious reason

I am experiencing loose, frequent bowel movements or diarrhea

I am experiencing constipation and sometimes using laxatives

I have allergies

I have been on an antibiotic in the last 2 years

I have skin issues e.g. rosacia or acne

I have coverage and I am interested in a dietitian consult?

Thanks for submitting!

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300 Rossland Rd E Suite 202

Ajax, ON L1Z 0M1

Tel: (289) 660-2761

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