Download Page Gut Health Assessment (pre) Sandia Proprietary Information

Gut Health Assessment (pre)
Sandia Proprietary Information
Personally Identifiable Information (PII) when completed,
please fax to Preventive Health: (505) 844-4091.
Name:
Age:
Gender:
Height:
Date:
Current Weight:
For PH Staff:
☐ 21-day recommended
☐ 21-day pending HMC review
☐ HMC/GI referral
BMI: ________
Do you have GERD? ☐ Yes ☐ No If yes, for how long? __________
Do you take medication for GERD? ☐ Yes
☐ No
About how long have you been taking GERD medication? __________
Do you have reflux when you go to bed or while sleeping? ☐ Yes ☐ No
Hiatal hernia? ☐ Yes ☐ No
Do you use tobacco? ☐ Yes ☐ No
Is your waist circumference > 35 inches (females) > 40 inches (males)? ☐ Yes ☐ No
Are you currently under the care of a physician for any digestive issues? ☐ Yes ☐ No
Have you ever had a colonoscopy or endoscopy preventive screening and/or issues with your digestion?
If so, what tests have been done, when were they done and what were results?
☐No ☐If yes, please complete below:
Why was it done?
Results/ Recommendations
1
Year it was done
Page
Name of test
Gut Health Assessment (pre)
Sandia Proprietary Information
Personally Identifiable Information (PII) when completed,
please fax to Preventive Health: (505) 844-4091.
Are you taking prescribed medications or over the counter medications for
your digestion? Some common digestive aids would include, but are not
limited to, the following examples: Omeprazole, Nexium, Prilosec, Pepcid, Zantac, Tums,
Pepto-Bismol, Colace, Dulcolax, Metamucil, Milk of Magnesia, Ex-Lax, Gas-X, Maalox,
☐No, no over the counter or prescription medications for my digestion
☐Yes, occasionally I take over the counter or prescription medications for my digestion
☐Yes, I routinely take over the counter or prescription medication for my digestion
☐Yes, I routinely take over the counter medication and prescription medication for my digestion
Do you have any of the following issues? Please check any or all that apply.
☐Bright red blood in the stool
☐Dark tarry stools
☐Coughing or vomiting up blood
☐Anemia that has not already been addressed by a doctor
☐Recurrent vomiting
☐Difficulty, discomfort or pain with swallowing
☐Involuntary weight loss
☐Chronic nausea or chronic diarrhea which you have never address with a doctor
☐Recurrent gastrointestinal pain which you have never address with a doctor
Do you have any of the following chronic health conditions? Please check any
or all that apply.
☐Diabetes
☐High blood pressure
In the past 7days, how many days per week have you experienced these symptoms:
1 day
2-3 days
4-7 days
Pre Total GERDQ: _________
Please Note: Chest pain that is not a burning feeling behind your breastbone or has any other features
that concern you should be discussed with your doctor or in an Emergency Room setting.
2
0 days
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Symptom:
Burning feeling behind the breastbone (heartburn)
Stomach contents moving up to the throat or mouth
(regurgitation)
Pain in the middle of the upper stomach area
Nausea
Trouble getting a good night's sleep because of heartburn or
regurgitation
Need for over-the-counter medicine for heartburn or
regurgitation (such as Tums, Rolaids, Maalox, or other antacids),
in addition to the medicine your doctor prescribed
Gut Health Assessment (pre)
Sandia Proprietary Information
Personally Identifiable Information (PII) when completed,
please fax to Preventive Health: (505) 844-4091.
On average I have at least one bowel movement:
☐ Daily
☐ Every 1-2 Days
☐ Every 3 Days
☐ Weekly
☐ Irregular (could be daily for a while then become every three days to a week)
On average I have:
☐ 1-3 bowel movements per day
☐ Four or more bowel movements per day
☐ Daily Frequency tends to be irregular sometimes 0-3 or >4 movements per day
Please use chart below to answer the following question.
On average my stools are most like:
☐Type 1
☐Type 2
☐Type 3
☐Type 4
☐Type 5
☐Type 6
☐Type 7
Page
3
☐ My stool type is inconsistant and regularly varies
Gut Health Assessment (pre)
Sandia Proprietary Information
Personally Identifiable Information (PII) when completed,
please fax to Preventive Health: (505) 844-4091.
Stanford Presenteeism Scale (SPS 6) Form
Below we would like you to describe your work experiences in the past month. These experiences may
be affected by many environmental as well as personal factors and may change from time to time. For
each of the following statements, please select one of the following responses to show your agreement or
disagreement with this statement in describing your work experiences in the past month.
Strongly
Somewhat
Uncertain
Somewhat
Strongly
Disagree
Disagree
About
Agree
Agree
Agreement
Because of my digestive health, the
stresses of my job were much
harder to handle.
Despite having my digestive health,
I was able to finish hard tasks in my
work.
My digestive health distracted me
from taking pleasure in my work.
I felt hopeless about finishing certain
work tasks, due to my digestive
health concern.
At work, I was able to focus on
achieving my goals despite my
digestive health.
Despite having my digestive health,
I felt energetic enough to complete
my work.
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For a total sense of your wellbeing please complete your Medical Symptoms Questionnaire (MSQ) and
report your total score here. Please keep the original form so you can compare your pre/post
results. Please make sure to discuss any individual areas of concern with your doctor. (The MSQ was
provided as a handout in Healthy Gut Session 1.)
Post MSQ Score Grand Total: __________
4
Pre SPS-6 Total Score: _________