Choose your biological genderFemaleMaleDiverse

Choose your Country of ResidenceAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, Democratic Republic of the CongoCook IslandsCosta RicaCote D'IvoireCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and Mcdonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran, Islamic Republic ofIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacaoMacedonia, the Former Yugoslav Republic ofMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States ofMoldova, Republic ofMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territory, OccupiedPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSerbia and MontenegroSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province of ChinaTajikistanTanzania, United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.s.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe

Section A: Medical history
Are you experiencing any of the following conditions? Please select one or more.

---Irritable bowel syndromeGastric ulcerUlcerative colitisinflammatory bowel disease (Crohn)Constipation/DiarrheaHeartburnAcid refluxAbdominal pain or discomfortBloating or excessive gasAutoimmune problems, such as thyroid issues, rheumatoid arthritis and type 2 DiabetesSugar cravingLactose intoleranceUnexplained mood disordersUnexplained fatigue or sluggishnessUnexplained weight gain or lossLiver cirrhosisNone of the above

Section B: lifestyle and habits:

1.Smoking status:

Do you smoke, or have you smoked?YesFormer smokerNo

Are you exposed to secondhand smoke?NoYesNeverRarely/Occasionally

2. Alcohol consumption:

How often do you have alcoholic drinks?NeverRarely (once a month or less)Occasionally (1-2 times a month)Moderately (1-2 times a week)Regularly (3-4 times a week)Daily

Choose your relevant type you prefer to drink:BeerWineSpiritsLiqueursFortified WinesNot Applicable

3. Dietary habits:

How would you describe your current overall dietary pattern?Mediterranean DietVegetarian DietVegan DietFlexitarian DietPaleolithic DietKetogenic (Keto) DietGluten-Free DietLow-FODMAP DietIntermittent FastingNon-Specific

How frequently do you consume foods that are high in added sugars (e.g., sugary beverages, sweets, desserts)?Choose approx. range.Multiple times a dayonce a dayseveral times a weekrarelynever

Do you have any food intolerances or sensitivities that affect your dietary choices?NoLactose IntoleranceGluten SensitivityCeliac DiseaseShellfish AllergyFish AllergyTree Nut AllergyPeanut AllergySoy AllergyEgg AllergyOther Food Sensitivities

How often do you consume processed or fast food?Multiple times a dayonce a dayseveral times a weekrarelynever

Probiotics are foods or supplements that contain live microorganisms intended to maintain or improve the "good" bacteria (normal microflora) in the body while Prebiotics are foods (typically high-fiber foods) that act as food for human microflora. Prebiotics are used with the intention of improving the balance of these microorganisms.

Do you consume probiotics?NoYoghurtKefirSauerkrautKimchiKombuchaTampeh

Do you consume prebiotics?NoChicory rootGarlicOnionsBananasOats

Did you take any of these pre/probiotics during the last month?YesNo

Section C: medications and supplements

When was your last time to take an antibiotic?1 month ago1 to 6 months ago6 or more months ago

Section D: symptoms and digestive health

What is your current bowel habit?Regular bowel movementsDaily bowel movementsEvery other dayMultiple times a dayIrregular bowel movementsConsistent constipationConsistent diarrhea

Have you experienced any recent changes in your bowel habits compared to your usual or previous patterns?YesNo

Have you ever undergone any gastrointestinal surgeries or procedures? Please select one or more.

Hernia repairIntestinal surgeriesBariatric surgeryPancreatectomyHepatectomyEsophagectomyGastrectomyColectomyCholecystectomyAppendectomyNone of the above

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