IBS Support Program Intake Form

Your First Step Toward Healing Begins Here

IBS Support Program Intake Form

Full Name

Phone Number

Birth Date

Have you been diagnosed with IBS by a doctor?

If yes, what type of IBS do you have?

Which of the following symptoms do you experience regularly? (Select all that apply) Bloating Abdominal Pain Diarrhea Constipation Sudden changes in bowel habits

How often do these symptoms occur?

How much have these symptoms affected your daily life?

Have these symptoms prevented you from social, work, or family activities?

If yes, please provide a brief explanation

Are you currently receiving treatment for IBS?

If yes, what type of treatment?

Have previous treatments been effective?

Are you willing to track your symptoms and diet daily for 6 weeks?

Do you have access to a recommended device (e.g., FoodMarble or our proprietary device)?

What is 6 + 8?