Form Testing - IBS Clinic

Section 1 of 21

📍 Basic Details Part 1

Full Name: *

Please enter your full name

Age: *

Please enter your age

Gender: *

Male

Female

Other

Please select your gender

City & Country: *

Please enter your city and country

Mobile Number (WhatsApp): *

Please enter your mobile number

Email ID: *

Please enter a valid email address

Section 2 of 21

📍 Basic Details Part 2

Preferred Language: *

Please enter your preferred language

How did you find us? *

Doctor Referral

Dietitian

Instagram

Google

Patient Reference

Other

Please select at least one option

Preferred Consultation Mode: *

Video Call

Phone

In-Person (Mumbai)

Please select your preferred consultation mode

Best Time to Contact (IST): *

Please enter your preferred contact time

Section 3 of 21

🧭 Health Concerns Part 1

How long have these been bothering you? *

Weeks

Months

Years

Please select duration

Check symptoms you frequently experience: *

🟧 Gastrointestinal Symptoms:

Hard/dry stools

Incomplete evacuation

Urge after meals

Excessive gas/bloating

Mucus in stool

Section 4 of 21

🧭 Health Concerns Part 2

Check symptoms you frequently experience (continued): *

🟧 Gastrointestinal Symptoms (continued):

Diarrhea

Alternating bowel habits

Abdominal pain

Feeling full quickly

Rectal pain/piles

Section 6 of 21

🪑 Bowel Habits Part 1

Frequency of bowel movement (BM): *

Daily

Alternate Days

Once in 2–3 days

Rarely

Please select frequency

Bristol Stool Type: *

Type 1 – Hard lumps

Type 2 – Lumpy

Type 3 – Cracked

Type 4 – Smooth

Please select Bristol Stool Type

Section 7 of 21

🪑 Bowel Habits Part 2

Bristol Stool Type (continued): *

Type 5 – Soft blobs

Type 6 – Mushy

Type 7 – Liquid

Please select Bristol Stool Type

Is your BM complete and satisfying? *

Yes

Please select an option

BM Time: *

Morning

Post Meals

Irregular

Please select BM time

Section 8 of 21

🪑 Bowel Habits Part 3

Do you get the urge to pass stool after meals? *

Yes

Please select an option

But stool doesn’t come out / only gas? *

Yes

Please select an option

Do you strain or sit too long? *

Yes

Average minutes you sit for BM:

Please select an option

Section 9 of 21

🪑 Bowel Habits Part 4

Do you feel fresh after BM? *

Yes

Please select an option

Do laxatives / fiber / probiotics work for you? *

Yes

Worsen symptoms

Please select an option

Section 11 of 21

🍲 Food Symptoms Part 2

Meal Triggers (continued): *

Cold or raw salads

Fruits / juices

Pulses/legumes

High fiber foods

Others:

Please select at least one trigger or specify other

Section 12 of 21

🔬 Diagnosis Part 1

Have you been diagnosed with any of the following? *

IBS – C / D / M:

Gastrocolic Reflex Dysfunction

SIBO / Candida

PCOS

Thyroid:

Hypo

Hyper

Please select at least one diagnosis

Section 13 of 21

🔬 Diagnosis Part 2

Have you been diagnosed with any of the following? (continued) *

Diabetes or Prediabetes

Acid Reflux / GERD / Gastritis

Anxiety / Depression

Hemorrhoids / Anal fissure

Appendectomy / Gallbladder removal

Colitis / Crohn’s / IBD

Others:

Please select at least one diagnosis or specify other

Section 14 of 21

🔬 Diagnosis Part 3

Past Tests Done: *

Colonoscopy

USG Abdomen

Stool Culture / PCR

SIBO Breath Test

Hormonal Profile

Please select at least one test

Section 15 of 21

🔬 Diagnosis Part 4

Past Tests Done (continued): *

Thyroid Panel

Blood Work

Others:

(Whatsapp reports or email them to info@ibsclinic.com)

Please select at least one test or specify other

Section 16 of 21

💊 Treatment Part 1

Which of the following have you tried? *

Allopathic medications:

Antispasmodics / SSRIs / Antidepressants

Ayurvedic or Homeopathic treatment

Panchakarma / Detox

Please select at least one treatment

Section 17 of 21

💊 Treatment Part 2

Which of the following have you tried? (continued) *

Diet plans from nutritionist

Laxatives / Enemas / Isabgol

Probiotics / Prebiotics / Enzymes

Yoga / Meditation / Pranayama

Others:

Please select at least one treatment or specify other

Results: *

Improved a lot

Slight improvement

No benefit

Got worse

Please select results

Section 18 of 21

🌱 Diet Part 1

Diet Pattern (check all that apply): *

Vegetarian

Vegan

Non-vegetarian

Eggetarian

Gluten-free

Please select at least one diet pattern

Section 19 of 21

🌱 Diet Part 2

Diet Pattern (continued): *

Dairy-free

Low FODMAP

Keto

Intermittent Fasting

Please select at least one diet pattern

Known Food Intolerances / Allergies:

Section 20 of 21

🌿 Medicine History Part 1

Picture of tongue (for Ayurvedic analysis):

Choose Image
📷

No image selected

Please upload a clear picture of your tongue for Ayurvedic analysis

Prakriti (if known): *

Vata

Pitta

Kapha

Dual/Tridoṣic

Unknown

Please select your Prakriti

Previous Ayurvedic Panchakarma / Therapies:

Herbal formulations used:

Section 21 of 21

📌 Consent

I confirm that all the above details are true to my knowledge.

I give my consent for evaluation, treatment, and follow-up via IBSClinic.com.

I understand this clinic does not offer emergency care or surgery services.

Please accept all consent terms

Signature (if offline):

Date: *

Please enter date

🌿 IBSClinic.com – New Patient Consultation Form

📍 Basic Details Part 1

📍 Basic Details Part 2

🧭 Health Concerns Part 1

🧭 Health Concerns Part 2

🧭 Health Concerns Part 3

🪑 Bowel Habits Part 1

🪑 Bowel Habits Part 2

🪑 Bowel Habits Part 3

🪑 Bowel Habits Part 4

🍲 Food Symptoms Part 1

🍲 Food Symptoms Part 2

🔬 Diagnosis Part 1

🔬 Diagnosis Part 2

🔬 Diagnosis Part 3

🔬 Diagnosis Part 4

💊 Treatment Part 1

💊 Treatment Part 2

🌱 Diet Part 1

🌱 Diet Part 2

🌿 Medicine History Part 1

📌 Consent

Thank You!

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