What is your gender? *

Male

Female

Do you have any form of active cancer that you are currently receiving chemotherapy or radiation to treat? *

Yes

Do you regularly experience any of the following? *

Bloating

Stomach pain/cramps

Irregular bowel movements

Constipation

Diarrhea

Nausea

Heartburn/reflux

None of the above

Have you ever been diagnosed with any of the following: *

Irritable Bowel Syndrome

Crohn's Disease

Ulcerative colitis

Gastritis

Leaky Gut Syndrome

None of the above

How long have you been dealing with digestive symptoms? *

Less than 3 months

3-12 months

1-3 years

3+ years

I don’t have symptoms, I’m just curious

Have you tried any of the following to improve your gut health? *

Prescription meds

Over-the-counter antacids or laxatives

Dietary changes (gluten-free, low-FODMAP, etc)

Probiotics

Functional medicine protocols

None of the above

First Name

Last Name

Date of birth

Phone

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