Gut Health Questionnaire - Equilibrium Healthcare

Participant Name

Name*

Given Name Surname

Date of Birth

Gender

Telephone Number: (Mobile)

Email*

Home Address

Street Address Suburb Post Code

Please use the following checklist to record any changes in your health conditions since beginning the microbiome management program. This information will help us assess the impact of microbiome interventions on your health.

General wellbeing

1. Energy levels*

No change in energy levels
Increased energy (e.g., more active, less fatigue)
Decreased energy (e.g., more tired, difficulty staying active)

If applicable, please describe any specific improvements or issues:

2. Mood and Mental Health*

No change in mood
Improved mood (e.g., feeling happier, less anxious/depressed)
Worsened mood (e.g., feeling more anxious, depressed, or irritable)

Please describe any specific changes:

3. Sleep Patterns*

No change in sleep
Improved sleep (e.g., falling asleep more easily, better quality sleep)
Worsened sleep (e.g., trouble sleeping, waking up frequently)

Please provide any details on changes:

Digestive Health

4. Bloating and Gas*

No change
Decreased bloating/gas
Increased bloating/gas

Please describe the changes or triggers:

5. Stool Consistency*

No change
More regular (e.g., stools are more consistent or easier to pass)
Less regular (e.g., constipation or diarrhea)

Please describe any changes in frequency or consistency:

6. Abdominal Pain or Discomfort*

No change
Reduced pain/discomfort
Increased pain/discomfort

If applicable, please detail any changes:

Immune System and Infections

7. Frequency of Illnesses*

No change
Fewer illnesses (e.g., fewer colds or infections)
More frequent illnesses

Please describe any illnesses, including duration and symptoms:

8. Allergic Reactions*

No change
Fewer allergic reactions (e.g., skin rashes, nasal congestion)
More frequent allergic reactions

Describe any specific reactions:

Skin Health

9. Skin Conditions (e.g., acne, eczema, psoriasis)*

No change
Improved (e.g., fewer breakouts, less inflammation)
Worsened (e.g., more breakouts, dryness, or irritation)

If applicable, please provide details:

10. Skin Appearance (e.g., texture, dryness, oiliness)*

No change
Improvement (e.g., smoother, more hydrated skin)
Worsening (e.g., more dry or oily skin)

Please describe any specific changes:

Weight and Metabolism

11. Body Weight*

No change
Weight loss (e.g., lost a few pounds)
Weight gain (e.g., gained a few pounds)

Please provide any relevant details or context:

12. Appetite and Cravings*

No change
Decreased appetite (e.g., feeling less hungry or satisfied longer)
Increased appetite (e.g., more frequent hunger or cravings)

Please specify any observed changes:

Other Health Conditions

13. Chronic Conditions (e.g., IBS, diabetes, autoimmune disorders)*

No change
Improvement in symptoms (e.g., less pain, better management)
Worsening of symptoms

If applicable, please provide specific symptoms and changes:

14. Any New Symptoms or Health Concerns*

No new symptoms
New symptoms (e.g., headaches, joint pain, etc.)

Please describe any new or unexpected symptoms:

Overall Health Perception

15. How would you rate your overall health since starting the microbiome management program?*

Much improved
Slightly improved
No change
Slightly worsened
Much worsened

Please elaborate on your rating:

Additional Comments or Observations

Please feel free to share any other thoughts, concerns, or experiences related to your health and microbiome management that were not captured in the above sections:

Phone

This field is for validation purposes and should be left unchanged.

Patient Health & Symptom Tracking Questionnaire