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Women's Health Coaching
- Constipation Freedom Program
- Gut Reset Session
Physiotherapy & Wellness for Women
Pregnancy & Postnatal Care
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Gut Reset Session Intake Form

Your Name

Date of Birth

How many bowel movements do you typically have per week?

Hard and dry

Takes effort to pass

Feels incomplete

Normal and easy

Changes every day

Do you ever experience the following after eating? (tick all that apply)

Bloating

Gas

Cramping

A heavy or full feeling

No digestive discomfort

Roughly how many servings of high-fiber foods do you eat per day? (eg. 1 serving = ½ cup beans, 1 apple, 1 slice wholegrain bread, 1 tbsp seeds, etc.)

0-2

3-5

6-8

9 or more

Not sure

Which of these do you eat most days? (tick all that apply)

Whole grains (oats, brown rice, quinoa)

Beans or lentils

Raw vegetables

Cooked vegetables

Chia/flax/hemp seeds

Fruit (with skins)

None of these

How do high-fiber foods usually make you feel?

Fine—I digest them well.

Gassy or bloated.

I avoid them — they make symptoms worse.

I’m not sure—I haven’t paid much attention.

Have you ever been told to eat more fiber?

Yes, and I’ve tried.

Yes, but I wasn’t sure how or what to eat?

No.

I’ve heard it helps but I don’t know what’s right for me.

How much water do you usually drink per day?

Less than 1L

Around 1–1.5L

2L or more

I’m not sure

What’s your top priority right now?

Feel more regular and comfortable.

Understand what to eat for my gut.

Reduce bloating/gas.

All of the above.

In your own words, what would you most like help with in this session? (Short paragraph)

On a scale of 1–10, how motivated are you to improve your gut health right now? (1 = curious but unsure, 10 = completely ready to change)

Have you made changes to your diet or fiber intake before?

Yes, I’ve tried increasing fiber.

Yes, I’ve tried cutting back on certain foods.

I’ve made some changes, but not sure what worked.

No, I haven’t tried anything yet.

What’s your biggest frustration when it comes to your digestion or gut health? (Optional short answer)

Is there anything else you'd like me to know before we meet? (Optional)

Location

Physio & Wellness Hub

Unit 2
Carlisle House, Adelaide Road, Bray, Co. Wicklow, A98 K2Y3

Opening hours

Mon & Thu: 9am - 9pm

Tue & Wed: 9am - 3pm

Sat: 9am - 3.30pm

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