Gut Health Questionnaire | Gut Health Monitor

Demographic Data

1. Aggressive Behaviors

Name

Sex *MaleFemale

Date of Birth

Age

Place of Birth

Birth Weight

Phone

Email Address

Diagnosis

Case History

Subjective Global Assessment

First 1000 Days

Was your baby fed during the golden hour? *YesNo

Why?

Was the baby able to latchYesNo

Was your baby exclusively breastfed for 6 monthsYesNo, give the reason

Why?

Was your baby fed on formula?Yes, How long?No

How long?

How long was your baby breastfed?

At what age was the weaning started?

What was the type of weaning?

Were there any colic issues?

When was the potty training started?

Anthropometric

Height

Weight

Head circumference

MUAC

SFT

BMI Percentile

BMR

Biochemical

Hemoglobin

Dietary

Day Recall

Breakfast

Lunch

Snacks

Dinner

Food Frequency Questionnaire

Cereals: Daily

Cereals: Weekly

Cereals: Often

Cereals: Rarely

Rice : Daily

Rice : Weekly

Rice : Often

Rice : Rarely

Ragi : Daily

Ragi : Weekly

Ragi : Often

Ragi : Rarely

Wheat : Daily

Wheat : Weekly

Wheat : Ofetn

Wheat : Rarely

Jowar : Daily

Jowar : Weekly

Jowar : Often

Jowar : Rarely

Pulses : Daily

Pulses : Weekly

Pulses : Often

Pulses : Rarely

Milk and milk products : Daily

Milk and milk products : Weekly

Milk and milk products : Often

Milk and milk products : Rarely

Vegetables : Daily

Vegetables : Weekly

Vegetables : Often

Vegetables : Rarely

Fruits : Daily

Fruits : Weekly

Fruits : Often

Fruits : Rarely

Meat : Daily

Meat : Weekly

Meat : Often

Meat : Rarely

Packed food/ Ultra processed foods : Daily

Packed food/ Ultra processed foods : Weekly

Packed food/ Ultra processed foods : Often

Packed food/ Ultra processed foods : Rarely

Gut Health

Does your child experience constipation?

How often is your child brain fogged? ation?

• Does your child feel nauseous, if yes how often. Is there any food /s trigger it? d? ation?

• Do you see any changes in eating pattern after a panic attack? Can it be described ? ation?

• Does your child complain about heart burn and abdominal pain attern after a panic attack? Can it be described ? ation?

• Do you notice irregularities in breathing? attern after a panic attack? Can it be described ? ation?

Is the child diagnosed with IBS?

• Do you find your child ruminating often?

• Do you notice regurgitation of recently ingested food?often?

Does the child experience pain on stooling? ften?

Smelly stool? ften?

How often do they fall sick? often?

Any recent antibiotic usage?

Any food allergy?

Any self- mutilation?

Does the child get a sound sleep?