Microbiome in Aging (MiA) Database
Home
Participant
Sample Size Query
Explore Database
Admin
Microbiome Survey
Login
Register
Microbiome Survey
Please carefully fill the following information. Answer all the questions.
Basic information
First Three Letters of your First Name:
First Three Letters of your Last Name:
First Three Letters of Physician Last Name:
Date of starting Postbiotics:
Last four digits of your Phone Number:
PoZibio consumption information
Please choose one of the following:
Before starting PoZibio
Day 30 after starting PoZibio
Day 60 after starting PoZibio
Digestion-associated Quality of Life Questionnaire (DQLQ)
Due to digestive events and experiences in the past 7 days:
Physical activities (running, walking, gardening, golfing, etc.) were unpleasant or avoided:
Never (0%)
Rarely (10%)
Occasionally (30%)
Sometimes (50%)
Frequently (70%)
Usually (90%)
Always (100%)
My usual appetite changed:
Never (0%)
Rarely (10%)
Occasionally (30%)
Sometimes (50%)
Frequently (70%)
Usually (90%)
Always (100%)
I was inconvenienced or physically uncomfortable:
Never (0%)
Rarely (10%)
Occasionally (30%)
Sometimes (50%)
Frequently (70%)
Usually (90%)
Always (100%)
I avoided certain foods:
Never (0%)
Rarely (10%)
Occasionally (30%)
Sometimes (50%)
Frequently (70%)
Usually (90%)
Always (100%)
I was self-conscious or bothered in public or around others:
Never (0%)
Rarely (10%)
Occasionally (30%)
Sometimes (50%)
Frequently (70%)
Usually (90%)
Always (100%)
I used restroom than I wanted:
Never (0%)
Rarely (10%)
Occasionally (30%)
Sometimes (50%)
Frequently (70%)
Usually (90%)
Always (100%)
I was distracted while doing various activities:
Never (0%)
Rarely (10%)
Occasionally (30%)
Sometimes (50%)
Frequently (70%)
Usually (90%)
Always (100%)
Social activities (Spending time with friends and family, going out to eat, etc.) unpleasant or avoided:
Never (0%)
Rarely (10%)
Occasionally (30%)
Sometimes (50%)
Frequently (70%)
Usually (90%)
Always (100%)
Consuming foods and beverages was less enjoyable:
Never (0%)
Rarely (10%)
Occasionally (30%)
Sometimes (50%)
Frequently (70%)
Usually (90%)
Always (100%)
THE GASTROINTESTINAL SYMPTOM RATING SCALE (GSRS)
Please read this first before answering the questions:
This survey contains questions about how you have been feeling and what it has been like DURING THE PAST WEEK. Mark the choice that best applies to you and your situation with a “select” in the circle:
Have you been bothered by PAIN OR DISCOMFORT IN YOUR UPPER ABDOMEN OR THE PIT OF YOUR STOMACH during the past week?
No discomfort at all (0%)
Minor discomfort (10%)
Mild discomfort (30%)
Moderate discomfort (50%)
Moderately severe discomfort (70%)
Severe discomfort (90%)
Very severe discomfort (100%)
Have you been bothered by HEARTBURN during the past week? (By heartburn we mean an unpleasant stinging or burning sensation in the chest.):
No discomfort at all (0%)
Minor discomfort (10%)
Mild discomfort (30%)
Moderate discomfort (50%)
Moderately severe discomfort (70%)
Severe discomfort (90%)
Very severe discomfort (100%)
Have you been bothered by ACID REFLUX during the past week? (By acid reflux we mean the sensation of regurgitating small quantities of acid or flow of sour or bitter fluid from the stomach up to the throat.):
No discomfort at all (0%)
Minor discomfort (10%)
Mild discomfort (30%)
Moderate discomfort (50%)
Moderately severe discomfort (70%)
Severe discomfort (90%)
Very severe discomfort (100%)
Have you been bothered by HUNGER PAINS in the stomach during the past week? (This hollow feeling in the stomach is associated with the need to eat between meals.):
No discomfort at all (0%)
Minor discomfort (10%)
Mild discomfort (30%)
Moderate discomfort (50%)
Moderately severe discomfort (70%)
Severe discomfort (90%)
Very severe discomfort (100%)
Have you been bothered by NAUSEA during the past week? (By nausea we mean a feeling of wanting to throw up or vomit.):
No discomfort at all (0%)
Minor discomfort (10%)
Mild discomfort (30%)
Moderate discomfort (50%)
Moderately severe discomfort (70%)
Severe discomfort (90%)
Very severe discomfort (100%)
Have you been bothered by RUMBLING in your stomach during the past week? (Rumbling refers to vibrations or noise in the stomach.):
No discomfort at all (0%)
Minor discomfort (10%)
Mild discomfort (30%)
Moderate discomfort (50%)
Moderately severe discomfort (70%)
Severe discomfort (90%)
Very severe discomfort (100%)
Has your stomach felt BLOATED during the past week? (Feeling bloated refers to swelling often associated with a sensation of gas or air in the stomach.):
No discomfort at all (0%)
Minor discomfort (10%)
Mild discomfort (30%)
Moderate discomfort (50%)
Moderately severe discomfort (70%)
Severe discomfort (90%)
Very severe discomfort (100%)
Have you been bothered by BURPING during the past week? (Burping refers to bringing up air or gas from the stomach via the mouth, often associated with easing a bloated feeling.):
No discomfort at all (0%)
Minor discomfort (10%)
Mild discomfort (30%)
Moderate discomfort (50%)
Moderately severe discomfort (70%)
Severe discomfort (90%)
Very severe discomfort (100%)
Have you been bothered by PASSING GAS OR FLATUS during the past week? (Passing gas or flatus refers to the need to release air or gas from the bowel, often associated with easing a bloated feeling.):
No discomfort at all (0%)
Minor discomfort (10%)
Mild discomfort (30%)
Moderate discomfort (50%)
Moderately severe discomfort (70%)
Severe discomfort (90%)
Very severe discomfort (100%)
Have you been bothered by CONSTIPATION during the past week? (Constipation refers to a reduced ability to empty the bowels.):
No discomfort at all (0%)
Minor discomfort (10%)
Mild discomfort (30%)
Moderate discomfort (50%)
Moderately severe discomfort (70%)
Severe discomfort (90%)
Very severe discomfort (100%)
Have you been bothered by DIARRHEA during the past week? (Diarrhea refers to a too frequent emptying of the bowels.):
No discomfort at all (0%)
Minor discomfort (10%)
Mild discomfort (30%)
Moderate discomfort (50%)
Moderately severe discomfort (70%)
Severe discomfort (90%)
Very severe discomfort (100%)
Have you been bothered by LOOSE STOOLS during the past week? (If your stools(motions) have been alternately hard and loose, this question only refers to the extent you have been bothered by the stools being loose.):
No discomfort at all (0%)
Minor discomfort (10%)
Mild discomfort (30%)
Moderate discomfort (50%)
Moderately severe discomfort (70%)
Severe discomfort (90%)
Very severe discomfort (100%)
Have you been bothered by HARD STOOLS during the past week? (If your stools (motions) have been alternately hard and loose, this question only refers to the extent you have been bothered by the stools being hard.):
No discomfort at all (0%)
Minor discomfort (10%)
Mild discomfort (30%)
Moderate discomfort (50%)
Moderately severe discomfort (70%)
Severe discomfort (90%)
Very severe discomfort (100%)
Have you been bothered by an URGENT NEED TO HAVE A BOWEL MOVEMENT during the past week? (This urgent need to go to the toilet is often associated with a feeling that you are not in full control.):
No discomfort at all (0%)
Minor discomfort (10%)
Mild discomfort (30%)
Moderate discomfort (50%)
Moderately severe discomfort (70%)
Severe discomfort (90%)
Very severe discomfort (100%)
When going to the toilet during the past week, have you had the SENSATION OF NOT COMPLETELY EMPTYING THE BOWELS? (This feeling of incomplete emptying means that you still feel a need to pass more stool despite having exerted yourself to do so.):
No discomfort at all (0%)
Minor discomfort (10%)
Mild discomfort (30%)
Moderate discomfort (50%)
Moderately severe discomfort (70%)
Severe discomfort (90%)
Very severe discomfort (100%)
If you are willing to leave a testimonial (first name and last initial, along with city (For example: JOHNY, Chicago) would be all that is used), please enter it here.
Submit
Reset
Microbiome in Aging (MiA) Database
Microbiome in Aging (MiA) Database