Your Gut Holds the Answers

✦ Guided wellness section

A. Personal Details

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Full Name

Age

Gender

Female Male Prefer not to say

Contact Number

Email ID

Occupation / Daily Routine (sedentary, active, mixed)

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◎ Guided wellness section

B. Digestive Symptoms

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7. Do you experience bloating?

Never Occasionally Frequently Almost daily

8. Do you feel gassy or experience excessive flatulence?

No Sometimes Often Very often

9. Do you feel heaviness or discomfort after meals?

Never Occasionally Frequently After most meals

10. Do you experience stomach or abdominal pain?

No Mild Moderate Severe / recurring

11. Do you feel lethargic, sleepy, or low in energy after meals?

Never Sometimes Often Almost always

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◎ Guided wellness section

C. Gut-Brain & Energy Connection

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12. Do you experience brain fog, poor focus, or low mental clarity?

Never Occasionally Frequently Daily

13. Do you feel low in energy even after adequate rest?

No Sometimes Often Almost always

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• Guided wellness section

D. Bowel Health

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14. Do you experience constipation without using laxatives?

No Occasionally Frequently Almost always

15. What best describes your stool type most days?

Sausage-shaped and smooth Semi-solid / soft Pebble-like / hard Floating

16. How often do you pass stools?

Once daily More than once daily Once every 2–3 days Less than 3 times per week

17. Do you notice mucus in your stool?

Never Occasionally Frequently

18. Does your stool have a strong or foul smell?

No Sometimes Often

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• Guided wellness section

E. Oral, Skin & External Signs

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19. Do you experience bad breath even with good oral hygiene?

No Occasionally Frequently

20. Do you have oral thrush or a white coating on the tongue?

No Occasionally Frequently

21. Do you experience acne, rashes, eczema, psoriasis, or other skin issues?

No Mild Moderate Severe / recurring

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◎ Guided wellness section

F. Upper Digestive Symptoms

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22. Do you experience acidity, heartburn, or acid reflux?

Never Occasionally Frequently Daily

23. Do you experience nausea?

No Sometimes Often

24. Do you experience frequent burping or belching?

No Sometimes Often

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❋ Guided wellness section

G. Lifestyle, Cravings & Sleep

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25. Do you experience sweet or sugar cravings?

Rarely Sometimes Often Very strong cravings

26. How is your sleep quality?

Deep and refreshing Light but okay Disturbed Poor or insufficient

27. Rate your current stress or anxiety levels:

Low Moderate High Very high

28. Do you struggle with stubborn weight despite consistent efforts?

No Slightly Yes Yes, significantly

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• Guided wellness section

H. Diet, Supplements & Habits

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29. Do you eat meals at regular times?

Yes Sometimes Rarely

30. Do you consume adequate water daily?

Yes Somewhat No

31. Are you currently taking any supplements?

Yes (please mention) No

31a. If yes, please mention the supplements

32. Have you taken antibiotics frequently in the past year?

No Once Multiple times

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• Guided wellness section

I. Goals & Medical History

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33. What improvements are you looking for in your gut health? (Energy, digestion, skin, weight, mental clarity, immunity, etc.)

34. Please mention any past medical history, diagnoses, or medications

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