Appointment

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SIBO Symptom Tracker

This form is for existing patients of Philadelphia Integrative Medicine who have a Follow Up Appointment scheduled and are being evaluated for SIBO. If you are not a patient, please do not complete this form.

Be sure to use your legal name listed on P2P portal account. If the name listed on this form does not match a P2P account, your form will not connect to your account and it will be deleted.
MM slash DD slash YYYY
On a scale of 0-4, 0 being never and 4 being always, how often do you experience the following?
How often do you have burping after meals?(Required)
How often do you have bloating after meals?(Required)
Does bloating get worse as the day goes on?(Required)
Do you feel better when you don’t eat?(Required)
How often do you have gas after meals?(Required)
How often do you have heartburn / acid reflux / GERD symptoms(Required)
How often do you experience diarrhea?(Required)
How often do you experience constipation?(Required)
Do you experience frequent brain fog?(Required)
Do you experience frequent fatigue?(Required)
Do you experience frequent UTIs?(Required)
Skin: do you experience rosacea, eczema, rashes or hives, atopic dermatitis, psoriasis?(Required)
Out of 48 points