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Directions (Use landscape mode on smartphones and do not use an iPad.)
Place the number that best describes your situation in the box to the right of the question.
0 = No or Rarely · 1 = Occasionally · 4 = Often · 8 = Frequently / YES
When a question is asked several times, don’t be annoyed — it applies to more than one organ.
Indigestion, food repeats on you after you eat
Excessive burping, belching and/or bloating following meals
Stomach spasms and cramping during or after eating
A sensation that food just sits in your stomach creating uncomfortable fullness, pressure and bloating during or after a meal
Bad taste in your mouth
Small amounts of food fill you up immediately
Skip meals or eat erratically because you have no appetite
Strong emotions, or the thought or smell of food aggravates your stomach or makes it hurt
Feel hungry an hour or two after eating a good-sized meal
Stomach pain, burning and/or aching over a period of 1-4 hours after eating
Stomach pain, burning and/or aching relieved by eating food; drinking carbonated beverages, cream or milk; or taking antacids
Burning sensation in the lower part of your chest, especially when lying down or bending forward
Digestive problems that subside with rest and relaxation
Eating spicy and fatty (fried) foods, chocolate, coffee, alcohol, citrus or hot peppers causes your stomach to burn or ache
Feel a sense of nausea when you eat
Difficulty or pain when swallowing food or beverage
When massaging under your rib cage on your left side, there is pain, tenderness or soreness
Indigestion, fullness or tension in your abdomen is delayed, occurring 2-4 hours after eating a meal
Lower abdominal discomfort is relieved with the passage of gas or with a bowel movement
Specific foods/beverages aggravate indigestion
The consistency or form of your stool changes (e.g., from narrow to loose) within the course of a day
Stool odor is embarrassing
Undigested food in your stool
Three or more large bowel movements daily
Diarrhea (frequent loose, watery stool)
Bowel movement shortly after eating (within 1 hour)
Discomfort, pain or cramps in your colon (lower abdominal area)
Emotional stress and/or eating raw fruits and vegetables causes abdominal bloating, pain, cramps or gas
Generally constipated (or straining during bowel movements)
Stool is small, hard and dry
Pass mucus in your stool
Alternate between constipation and diarrhea
Rectal pain, itching or cramping
No urge to have a bowel movement
An almost continual need to have a bowel movement
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