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Kickstart Questionnaire

What are your main symptoms or concerns? (Select any that apply)
How long have these symptoms or concerns been present?
Less than 1 month
1–3 months
3–6 months
6–12 months
1–2 years
2+ years

What does a typical day of eating look like for you?

How would you describe your appetite?
Strong / always hungry
Moderate
Low / often not hungry
Up and down

How often do you consume the following?

Alcohol:
Rarely
1–2 times per week
3–4 times per week
Most days
Caffeine (coffee/tea):
None
1 per day
2–3 per day
4+ per day
How many hours of sleep do you get on average per night?
Less than 5 hours
5–6 hours
6–7 hours
7–8 hours
8+ hours
How is your sleep quality?
Sleep well
Trouble falling asleep
Wake during the night
Wake unrefreshed
On average, how many steps do you do per day?
Less than 5,000
5,000–7,500
7,500–10,000
10,000+
How would you describe your stress levels?
Low
Moderate
High
What are your bowel movements typically like?
Daily and well-formed
Constipated (hard, difficult to pass)
Loose or urgent
Irregular
Bloating or discomfort
Other
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