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Doctor’s portal

Please fill out the questionnaires below:

Step 1

    Visit 1 - Patient enrolment

    Fill out the form below to register.

    Has your patient signed the consent form found on this link: Consent form for Research purposes?

    PATIENT DATA

    Birth sex:
    Age:

    Type of diet:

    Other type of diet

    Intestinal movement:
    Level of anxiety from 1 to 10:
    Is the patient a smoker?

    Is the patient suffering from any of the following issues: (select as many as apply to you)

    Other gastrointestinal issues

    Intake of antibiotics in the past 2 months?

    Frequency & reason

    Intake of any other medication, kindly list:
    1. Names of medication/s the patient has taken
    2. Duration for each medication taken
    3. List any side effects from the medications taken
    4. Indicate the intensity of the side effects for each medication


    Step 2

      Visit 2 - Patient follow-up

      Fill out the form below to register.

      PATIENT DATA

      Birth sex:
      Age:

      Type of diet:

      Other type of diet


      Intestinal movement:
      Level of anxiety from 1 to 10:
      Is the patient a smoker?

      Is the patient suffering from any of the following issues: (select as many as apply to you)

      Other gastrointestinal issues

      Intake of antibiotics in the past 2 months?

      Frequency & reason

      Intake of any other medication, kindly list:
      1. Names of medication/s the patient has taken
      2. Duration for each medication taken
      3. List any side effects from the medications taken
      4. Indicate the intensity of the side effects for each medication