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Gastro- Questionnaire
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Questionnaire

Gender.
Indicate your age group.
Where do you live? (City, Province/State)
What is your general health?
Do you have problems with any of these systems? (If yes, please check all that apply below)Yes
No
Gastrointestinal
Ears/Nose/Throat
Cardiovascular
Respiratory
Nervous
Allergies/Immunologic
Genitourinary
Musculoskeletal
Integumentary
Eyes
Mental
Endocrine
Blood/Lymph
Please Explain (ex. Disorder/Disease, Symptomes Associated, etc.):
If you checked Gastrointestinal, please describe symptomes further, including where feelings of pain are associated (for example; pain in the lower-right abdominal side, or pain in upper-right abdonimal area, etc.)
Do you smoke?Yes
No
  
All survey results will be posted statistically on the website and new questionnaires will be available to submit in upcoming weeks.