Check off which problem/s you are experiencing
Weight Gain
Chronic Fatigue
Crohns/Celiac
IBS/SIBO
Thyroid Disorder
Autoimmune Disorder
Something Else
On a scale of 1-10, one being hardly any pain and ten being unbearable, how would you rate your pain?
1
2
3
4
5
6
7
8
9
10
Please Describe your Pain/Discomfort
Diarrhea or Constipation
Headaches
Bloating
Heartburn
I feel tired after I eat
I crave certain foods
Something Else
How long have you had this problem? *
0-3 Months
3-12 Months
1-3 Years
Over 3 Years
How many doctors have you seen for this problem?
1
2
3
None
What have you tried in the past to correct the problem?
Acupuncture
Over The Counter (Pepto Bismol, Antiacids, Laxatives)
Surgery (Thyroid Removal, Gall bladder Removal)
Natural Alternatives (Essential Oils, Tea, etc
Something Else
Nothing
Do any of these apply to you?
I can't enjoy certain foods
I can't fall asleep
Constantly having to go to the bathroom
Bad Breath
I can't remember things as well
Irritable if meals are missed
What areas of your life are being negatively impacted?
Marriage/Relationships
Ability to Exercise
Work
Mood
Sleep
Energy
Something Else
On a scale of 0 - 5 how important is it for you to get this problem corrected?
1
2
3
4
5
Is there anything else you’d like to share with us regarding your goals?
First Name
*
Last Name
*
Phone
*
Email
*
Congrats, you qualify for a $109 Digestive Consultation and Exam! What time of day is it best to reach out to you to book?
Mornings
Afternoons
Evenings