Diet Survey
1
Your Condition
2
Your Diet & Lifestyle
Have you modified your diet since being diagnosed with IBD?
Yes
No
Do you find modifying your diet helps your symptoms?
Yes
No
Are there whole food types you avoid completely?
Choose all that apply
Gluten
Dairy
Nightshades
Sugar
Caffiene
Tap Water
Alcohol
Fibre
Red Meat
Eggs
Wheat
How many glasses of fluid do you drink per day?
Do you follow a particular diet?
Choose all that apply
Paleo
SCD
Low FODMAP
Low Residue
Gluten Free
Dairy Free
Lofflex
Vegan
Vegetarian
Liquid
Nightshade Free
Sugar Free
High Protien
Low Protien
Low Carb
High Carb
Other
Do you take any supplements?
Choose all that apply
Aloe Vera
Calcium
Fish Oil
Folic Acid
Glucosamine
Iron
Magnesium
Manuka Honey
Multivitamin
Prebiotics
Probiotics
Synbiotics
Turmeric
Vitamin A
Vitamin B Complex
Vitamin B12
Vitamin B6
Vitamin D
Wheatgrass
Whey Protein
Zinc
Other
How many units of alcohol do you drink per week?
How many hours do you sleep a day?
How many hours do you exercise per week?
What forms of exercise do you do?
Choose all that apply
Aerobics
Aquarobics
Badminton
Boxing
Climbing
Cycling
Dancing
Football
Golf
Martial Arts
Pilates
Rowing
Running
Squash
Swimming
Tennis
Walking
Weight Training
Yoga
Other
How much stress are you under?
None
A lot
How much do you worry about your IBD?
None
A lot
Next
3
Meat, Poultry, Fish & Eggs
4
Milk & Dairy
5
Grains, Beans & Legumes
6
Vegetables
7
Fruit
8
Nuts, Sugars & Other Foods
9
Drinks
10
Complete
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