Pre-exam interview
Hydrogen Breath Test (test substrate)* LactoseFructoseBacterial overgrowth (SIBO)
Your full name*
Age
Email
Phone (numbers only)*
Weight (kg)
Height (cm)
Occupation
Signs and symptoms that led you to take the test:
How long have you had these signs and symptoms:
Diseases under treatment HypertensionHepatitisAsthmaDefibrillatorDepressionCOPDDiabetesBronchitisPacemakerParkinson'sAnemiaNeurological disorderAnxietySmokingStrokeArrhythmiasHIVChronic coughThyroid disorderHeart attack/STENTChronic kidney disease
Medications for continuous use and their respective dosages
Allergies / Urticaria / Edema (Swelling) Eyes, Face, Lips and throat with use of medications or foods.
Do you follow any dietary restriction (diet) Lactose, Fructose, Gluten, Fodmaps or others. For how long:
Do you have any food intolerance? Which one? For how long?
Smoker? If yes, smoking is not allowed before or during the test. YesNo
Antibiotic in the last 30 days? Which one?
Have you had a colonoscopy or contrast X-ray of the colon in the last 30 days? YesNo
Laxatives in the last 7 days? Which one?
Probiotics in the last 7 days? Which one?
Previous abdominal surgeries? Which ones? For what reason?
Dental procedure in the last 7 days? YesNo
Do you use weight loss pens?
Do not take the test if you have fever and/or vomiting on the day of the exam or the day before.
Yes, I agree with the privacy policy
