Follow Up Visit Form

Rate each of the following symptoms based upon your typical health profile for the past 14 days.

Point Scale

0 – Never or almost never have the symptom

1 – Occasionally have it, effect is not severe

2 – Occasionally have it, effect is severe

3 – Frequently have it, effect is not severe

4 – Frequently have it, effect is severe

If you are being evaluated for SIBO, please also complete the SIBO Symptom Tracker.