Gut Health Quiz Question Template for Functional Medicine
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Gut Health Quiz Question Template for Functional Medicine
A ready-to-use set of 8 gut health assessment questions designed for functional medicine practitioners. This template evaluates digestive symptoms, food sensitivities, antibiotic history, and stress-gut interactions. Patient responses map to three clinical archetypes: Gut Barrier Compromised, Microbiome Dysbiosis, and Stress-Driven Gut Dysfunction — giving you a structured starting point for treatment.
PDF for printing as-is · DOCX to add your logo and customize in Word or Google Docs.
How to Use This Template
Download the Template
Grab the PDF above to print as-is, or the editable DOCX to customize the questions in Word or Google Docs before copying them into your tool.
Copy Into Your Assessment Tool
Copy the 8 questions below into any quiz builder, form tool, or assessment platform. Each question includes multiple-choice options and maps to specific clinical archetypes. Modify as needed to fit your clinical approach.
Or Automate With Brevlix
Instead of copying questions manually, Brevlix deploys this gut health assessment on your website in minutes. Scoring, archetype mapping, and patient report generation are handled automatically. Customize your branding and go live.
Template Content
Q1: Which of these do you experience regularly? (check all that apply)
☐ Bloating or gas after meals
☐ Irregular bowel movements
☐ Acid reflux or heartburn
☐ Food sensitivities
☐ Brain fog that correlates with digestive symptoms
Q2: In the past 2 years, have you taken antibiotics?
☐ Multiple rounds
☐ Once
☐ No
☐ Not sure
Q3: How often do your meals include the following? (check all that apply)
☐ Processed foods
☐ Fermented foods
☐ Diverse vegetables (5+ types per day)
☐ Gluten-containing grains
☐ Dairy products
Q4: Do your digestive symptoms change with stress?
☐ Significantly worse with stress
☐ Slightly worse with stress
☐ No change
☐ Not sure
Q5: How many bowel movements do you have per day?
☐ Less than 1 per day
☐ 1-2 per day
☐ 3 or more per day
☐ Unpredictable — varies widely
Q6: Do you experience any of the following? (check all that apply)
☐ Mucus in stool
☐ Undigested food in stool
☐ Urgency / difficulty holding
☐ None of these
Q7: Have you tried an elimination diet?
☐ Yes — and it helped
☐ Yes — but saw no change
☐ No, I have not tried one
Q8: Rate your overall digestive comfort on a scale of 1-5.
1 — Very uncomfortable
2
3 — Moderate
4
5 — Very comfortable
Clinical Archetypes:
See These Questions Working as a Live Assessment
This template is the paper version of Brevlix's gut health assessment — same archetypes, automated scoring, instant patient report. Try the live version the way your patients would.
Try the live gut assessment →Ready to deploy it on your website? Start free →
Frequently Asked Questions
What does the gut health quiz template assess?
This template evaluates digestive symptoms, food sensitivities, antibiotic history, stress-gut interactions, bowel movement patterns, and dietary habits. The 8 questions are designed to differentiate between three gut health archetypes: Gut Barrier Compromised, Microbiome Dysbiosis, and Stress-Driven Gut Dysfunction.
Can I modify the gut health questions?
Yes. The template is a starting point — you can add, remove, or rephrase questions to match your clinical approach. The archetype mapping framework is flexible enough to accommodate adjustments while preserving clinical relevance.
How are the archetypes mapped from patient responses?
Each response option contributes weighted points toward one or more archetypes. For example, bloating and irregular bowel movements point toward Gut Barrier Compromised, while antibiotic history and processed food consumption correlate with Microbiome Dysbiosis. The result is a multi-dimensional profile, not a single score.
How do I use this template in my practice?
Download the PDF, copy the questions into your existing quiz tool, or deploy through Brevlix for an automated solution. The template works as a pre-appointment screening tool, giving you structured digestive health data before the first consultation.