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Your First Step Toward Healing Begins Here
IBS Support Program Intake Form
Full Name
Email
Phone Number
Birth Date
Year
Month
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Day
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Have you been diagnosed with IBS by a doctor?
Select an option
Yes
No
If yes, what type of IBS do you have?
I don't know
IBS-D (Diarrhea-predominant)
IBS-C (Constipation-predominant)
IBS-M (Mixed)
Which of the following symptoms do you experience regularly? (Select all that apply)
Bloating
Abdominal Pain
Diarrhea
Constipation
Sudden changes in bowel habits
How often do these symptoms occur?
Select an option
Daily
Several times a week
Several times a month
How much have these symptoms affected your daily life?
Select an option
Very High
High
Moderate
Low
Very Low
Have these symptoms prevented you from social, work, or family activities?
Select an option
Yes
No
If yes, please provide a brief explanation
Are you currently receiving treatment for IBS?
Select an option
Yes
No
If yes, what type of treatment?
Have previous treatments been effective?
Select an option
Yes
No
Partially
Are you willing to track your symptoms and diet daily for 6 weeks?
Select an option
Yes
No
Do you have access to a recommended device (e.g., FoodMarble or our proprietary device)?
Select an option
Yes
No
Maybe
What is 7 + 5?
Submit
