We would like to assess which symptoms bother you the most. Please complete the questionnaire on the following pages.

The purpose of this questionnaire is to learn more about the health problems that people sometimes have with their stomach and intestines.

The questionnaire will take about 15 – 20 minutes to complete.

You may find that you have not had any of the symptoms that we ask you about. When this happens, you may be instructed to skip over the questions that do not apply to you. But do not skip questions unless you are told to do so.

If you are not sure about and answer, just answer as best as you can.

It is easy to miss questions, so please check that you have not left any out as you go.

You are not able to save and return to your survey so please complete the entire survey.

The information used in this questionnaire helps Alfred Health understand the nature and urgency of your condition, which assists us to arrange an appointment for you. The information you provide will form part of your medical record and will be kept confidential by Alfred Health. If you do not wish to provide the information electronically, please contact the Functional Gut Clinic on 9076 2104 and we will send you a paper version to complete.

Thank you for your time in completing this survey, it allows us to ensure that you are referred to the clinician that will be best suited at treating your symptoms.

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