Please complete the below form entirely, (*) indicates a required field.

Today's Date(XX-XX-XXXX):*

First Name:*

Last Name:*

Date of Birth(XX-XX-XXXX):*

Have you ever received care at Gastroenterology Associates of Gainesville? *
—Please choose an option—YesNo

Who was your previous Doctor: *
If you have never been seen by our practice, select New Patient, if you do not recall your previous provider select Unknown
—Please choose an option—New PatientUnknownScott A. Clark, MDSheraj Jacob, MDJohn L Kalarickal, MDNamita Pareek, MDVinni M. Reddy, MDNeeraj Sharma, MDAnkur Sheth, MDAndrew Lake, MDEvan Brady, MDDanielle Shelnut, MD

Which symptoms best describe you? Select all that apply.*
Accidental Loss or leakage of stool-sometimes unable to make it to the bathroom on timeFrequent, loose, watery stoolsBowel accidents while unaware-no warning and/or while asleepSudden or strong urge to go to the bathroomBowel accidents when passing gasNo bowel problems (if checked, please discontinue questionnaire)

How long have you had these symptoms?*

Approximately how many bowel incidents do you have per week?*

Have you tried medications to help your symptoms?*
—Please choose an option—YesNo

On a scale of 0 to 10, with 0 being no symptom relief and 10 being complete symptom relief, how much symptom
relief have these medications provided for you?* Select number.

0-No Relief12345678910-Complete symptom relief

Behavior modifications tried?* (e.g., lifestyle changes, fiber, diet changes, physical therapy, etc.)

On a scale of 0 to 10, with 0 being no frustration at all and 10 being extremely frustrated, what is your level of
frustration with your bowel control symptoms?* Select a number.

0-Not Frustrated12345678910-Very Frustrated

Are you interested in learning more about additional treatment alternatives to bowel medications?*
—Please choose an option—YesNo

Contact Name:*

Daytime Phone Number (XXX-XXX-XXXX):*

Email:

*By providing my email, I am consenting to have a Bowel Symptom Questionnaire confirmation email sent to the above listed email address.

Agreement/E-Signature Disclaimer*I AGREE
By selecting the "I agree" checkbox and filling in the below signature box I agree to the following: I acknowledge the risk of sending information by email and will not hold Gastroenterology Associates of Gainesville, P.C. responsible for any damages I may incur as a result of the transfer or use of this information. I understand the use or transmittal of this form does not create a physician-patient relationship. I am giving representatives from Gastroenterology Associates of Gainesville, P.C. permission to contact me between 8:00 am and 5:00 pm EST to discuss my bowel symptom questionnaire. In addition, I declare the information provided on this form, is to the best of my knowledge, true and correct.

Patient Acceptance:*
I, , agree to the terms and conditions listed above.

Important: After submission, please do not leave this form until you see the confirmation message.