Gut Check Questionnaire

For people 1 year of age and older with SHORT BOWEL SYNDROME (SBS) who are dependent on parenteral support (PS).

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A way to help you talk to a doctor about what you or your child is experiencing

“Talk to your doctor.” It’s a common phrase, but it can be hard to know what to talk about and which questions to ask.

To help start the conversation, our 5-minute interactive questionnaire can help you describe what you or your child might be experiencing. It also generates personalized talking points that you can print or email to yourself for easy reference at your next doctor's appointment.

Begin Questionnaire

First, tell us a little about you or the loved one you care for.

Select what best describes you.*

*Please select one answer. At least one answer is required. Please select one answer to continue questionnaire.

An adult age 18+

A caregiver for
someone age 1-17

Choose the option that applies.*

*Please select one answer.

At least one answer is required. Please select one answer to continue questionnaire.

I have a short bowel syndrome (SBS) diagnosis I’m not sure if I have SBS

My child has a short bowel syndrome (SBS) diagnosis I’m not sure if my child has SBS

Now let’s look at what you may be experiencing and your medical history.

Now let’s look at what your child may be experiencing and their medical history.

Which of the following are you currently experiencing?*

*Select as many that apply. At least one answer is required. Please select one answer to continue questionnaire.

Why we ask

Malnutrition, muscle weakness, weight loss, dehydration, and diarrhea/high ostomy outputs are some of the indicators that may point to SBS. Have questions? Your doctor can provide more information.

Which of the following is your child currently experiencing?*

*Select as many that apply. At least one answer is required. Please select one answer to continue questionnaire.

Malnutrition

Fluid and electrolyte deficiency

Growth and developmental delays

Motility disturbances

Diaper/stoma skin breakdown

Gallstones

Ulcers

Heartburn

My child isn't experiencing any of these

Why we ask

Growth and developmental delays, fluid and electrolyte deficiency (signs include headache, nausea, and vomiting) and malnutrition (signs include severe fatigue, muscle weakness, and weight loss) may point to malabsorption. Have questions? Your child’s doctor can provide more information.

SBS can result from a number of conditions. Which of these conditions resulted in intestine resection?*

*Select as many that apply. At least one answer is required. Please select one answer to continue questionnaire.

Vascular disease, a condition that affects the circulatory system or system of blood vessels

Crohn’s disease, where inflammation in the intestines may cause injury

Volvulus, when the intestine twists around itself causing bowel blockage

Injury, any penetrating or blunt trauma to the intestine

Other

Which of these conditions were present at your child’s birth or resulted in intestine resection?*

*Select as many that apply. At least one answer is required. Please select one answer to continue questionnaire.

Gastroschisis, a condition where the intestines stick out of the body

Midgut volvulus, where the intestines twist, cause blockage, and cut blood flow

Necrotizing enterocolitis, which occurs when the intestinal wall dies off

Intestinal atresia, when the intestines haven’t  formed correctly, leads to closures and infections

Hirschsprung’s disease, a condition where missing nerves in the intestine interrupt digestion

Other

What’s your required amount of parenteral support (PS)? Please enter amount and frequency below.

Weekly volume and Days per week are required fields.

Weekly volume (mL) Days per week

What’s PS?

PS includes and is often referred to as total parenteral nutrition (TPN) or intravenous (IV) fluids.

What’s your child's required amount of parenteral support (PS)? Please enter amount and frequency below.

At least one answer is required. Please select one answer to continue questionnaire.

Weekly volume (mL) Days per week

What’s PS?

PS includes and is often referred to as total parenteral nutrition (TPN) and intravenous (IV) fluids.

Which of the following are you currently experiencing?*

*Select as many that apply. At least one answer is required. Please select one answer to continue questionnaire.

Malnutrition

Muscle weakness

Weight loss

Dehydration

Dark-colored urine

Infrequent urine

Excessive thirst

Diarrhea/high ostomy output (8+ cups a day)

I’m not experiencing any of these

Why we ask

Malnutrition, muscle weakness, weight loss, dehydration, and diarrhea/high ostomy outputs are some of the indicators that may point to SBS. Have questions? Your doctor can provide more information.

Which of the following is your child currently experiencing?*

*Select as many that apply. At least one answer is required. Please select one answer to continue questionnaire.

Malnutrition

Fluid and electrolyte deficiency

Growth and developmental delays

Motility disturbances

Diaper/stoma skin breakdown

Gallstones

Ulcers

Heartburn

My child isn't experiencing any of these

Why we ask

Malnutrition, muscle weakness, weight loss, dehydration, and diarrhea/high ostomy outputs are some of the indicators that may point to SBS. Have questions? Your child’s doctor can provide more information.

Which activities do you miss out on because of time spent on PS?*

*Select as many that apply. At least one answer is required. Please select one answer to continue questionnaire.

Hobbies

School

Sleep and rest

Being with friends and family

Work

Other

None

Which activities does your child miss out on because of time spent on PS?*

*Select as many that apply. At least one answer is required. Please select one answer to continue questionnaire.

Hobbies

School

Sleep and rest

Being with friends and family

Work

Other

None

Which of the following specialists are you seeing based upon what you are experiencing?*

*Select as many that apply. At least one answer is required. Please select one answer to continue questionnaire.

Primary Care Physician

Gastroenterologist

Surgeon

Dietitian

Nurse Practitioner or Physician Assistant

Nephrologist

Other

None

Why we ask

A team of specialists can often work together to help you improve managing your condition or what you may be experiencing.

Which of the following specialists is your child seeing based upon what they are experiencing?*

*Select as many that apply. At least one answer is required. Please select one answer to continue questionnaire.

Primary Care Physician

Gastroenterologist

Surgeon

Dietitian

Nurse Practitioner or Physician Assistant

Nephrologist

Other

None

Why we ask

A team of specialists can often work together to help you improve managing your child's condition or what your child may be experiencing.

Have you experienced complications linked to long-term PS use?*

While PS can be lifesaving, risks and potentially life-altering complications may occur over time. Talk to your doctor about long-term PS-related complications you may be experiencing.

*Check all conditions that apply. At least one answer is required. Please select one answer to continue questionnaire.

Liver-related complications

Bone diseases

Kidney issues

Catheter-related complications like septic infections, blood clots, and loss of vascular access

Other

I’m not experiencing any complications

Has your child experienced complications linked to long-term PS use?*

While PS can be lifesaving, risks and potentially life-altering complications may occur over time. Talk to your child's doctor about long-term PS-related complications your child may be experiencing.

*Check all conditions that apply. At least one answer is required. Please select one answer to continue questionnaire.

Liver-related complications

Bone diseases

Kidney issues

Catheter-related complications like septic infections, blood clots, and loss of vascular access

Other

My child is not experiencing any complications

A good plan begins with the right goals. Let’s capture what those are so you can bring them to your upcoming appointment.

When it comes to managing your experience, you feel*:

*Please select one answer. At least one answer is required. Please select one answer to continue questionnaire.

Informed, I feel confident

Curious, I want to know more

Anxious, not knowing enough makes me uneasy

I’m not sure how I feel

List any goals you may have for managing your experience. You can refer to this list when speaking with the doctor and/care team on how to move forward.

A good plan begins with the right goals. Let’s capture what those are so you can bring them to your upcoming appointment.

When it comes to managing your child’s experience, you feel*:

*Please select one answer. At least one answer is required. Please select one answer to continue questionnaire.

Informed, I feel confident

Curious, I want to know more

Anxious, not knowing enough makes me uneasy

I’m not sure how I feel

List any goals you may have for managing your child’s experience. You can refer to this list when speaking with the doctor and/care team on how to move forward.

When it comes to managing your SBS, you feel*:

*Please select one answer. At least one answer is required. Please select one answer to continue questionnaire.

Informed, I feel confident

Curious, I want to know more

Anxious, not knowing enough makes me uneasy

I’m not sure how I feel

List any additional goals you may have for managing your condition. You can refer to this list when speaking with the doctor and/care team on how to move forward.

A good plan begins with the right goals. Let’s capture what those are so you can bring them to your upcoming appointment.

When it comes to managing your child’s SBS, you feel*: 

*Please select one answer. At least one answer is required. Please select one answer to continue questionnaire.

Informed, I feel confident

Curious, I want to know more

Anxious, not knowing enough makes me uneasy

I’m not sure how I feel

List any goals you may have for managing your child’s condition. You can refer to this list when speaking with the doctor and/care team on how to move forward.

You're all set

Now email or print your personalized talking points. And remember, talking openly and honestly about managing your condition with your doctor is important so that you can get the care you need.

Now email or print your personalized talking points. And remember, talking openly and honestly about your child’s condition with the doctor is important so that your child can get the care they need.

Now email or print your personalized talking points. And remember, talking openly and honestly about managing your experience with your doctor is important so that you can get the care you need.

Now email or print your personalized talking points. And remember, talking openly and honestly about your child’s experience with the doctor is important so that your child can get the care they need.

Download Send email

Retake questionnaire

Gut Check Questionnaire

A way to help you talk to a doctor about what you or your child is experiencing

Select what best describes you.*

Choose the option that applies.*

Now let’s look at what you may be experiencing and your medical history.

Now let’s look at what your child may be experiencing and their medical history.

Which of the following are you currently experiencing?*

Which of the following is your child currently experiencing?*

SBS can result from a number of conditions. Which of these conditions resulted in intestine resection?*

Which of these conditions were present at your child’s birth or resulted in intestine resection?*

What’s your required amount of parenteral support (PS)? Please enter amount and frequency below.

What’s PS?

What’s your child's required amount of parenteral support (PS)? Please enter amount and frequency below.

What’s PS?

Which of the following are you currently experiencing?*

Which of the following is your child currently experiencing?*

Which activities do you miss out on because of time spent on PS?*

Which activities does your child miss out on because of time spent on PS?*

Which of the following specialists are you seeing based upon what you are experiencing?*

Which of the following specialists is your child seeing based upon what they are experiencing?*

Have you experienced complications linked to long-term PS use?*

Has your child experienced complications linked to long-term PS use?*

When it comes to managing your experience, you feel*:

List any goals you may have for managing your experience. You can refer to this list when speaking with the doctor and/care team on how to move forward.

When it comes to managing your child’s experience, you feel*:

List any goals you may have for managing your child’s experience. You can refer to this list when speaking with the doctor and/care team on how to move forward.

When it comes to managing your SBS, you feel*:

List any additional goals you may have for managing your condition. You can refer to this list when speaking with the doctor and/care team on how to move forward.

When it comes to managing your child’s SBS, you feel*:

List any goals you may have for managing your child’s condition. You can refer to this list when speaking with the doctor and/care team on how to move forward.

You're all set

Other popular topics

IMPORTANT SAFETY INFORMATION

GATTEX may cause serious side effects, including:

The most common side effects of GATTEX in adults include:

What should I tell my healthcare provider before using GATTEX?

What is GATTEX?

Gut Check Questionnaire

A way to help you talk to a doctor about what you or your child is experiencing

Select what best describes you.*

Choose the option that applies.*

Now let’s look at what you may be experiencing and your medical history.

Now let’s look at what your child may be experiencing and their medical history.

Which of the following are you currently experiencing?*

Which of the following is your child currently experiencing?*

SBS can result from a number of conditions. Which of these conditions resulted in intestine resection?*

Which of these conditions were present at your child’s birth or resulted in intestine resection?*

What’s your required amount of parenteral support (PS)? Please enter amount and frequency below.

What’s PS?

What’s your child's required amount of parenteral support (PS)? Please enter amount and frequency below.

What’s PS?

Which of the following are you currently experiencing?*

Which of the following is your child currently experiencing?*

Which activities do you miss out on because of time spent on PS?*

Which activities does your child miss out on because of time spent on PS?*

Which of the following specialists are you seeing based upon what you are experiencing?*

Which of the following specialists is your child seeing based upon what they are experiencing?*

Have you experienced complications linked to long-term PS use?*

Has your child experienced complications linked to long-term PS use?*

When it comes to managing your experience, you feel*:

List any goals you may have for managing your experience. You can refer to this list when speaking with the doctor and/care team on how to move forward.

When it comes to managing your child’s experience, you feel*:

List any goals you may have for managing your child’s experience. You can refer to this list when speaking with the doctor and/care team on how to move forward.

When it comes to managing your SBS, you feel*:

List any additional goals you may have for managing your condition. You can refer to this list when speaking with the doctor and/care team on how to move forward.

When it comes to managing your child’s SBS, you feel*:

List any goals you may have for managing your child’s condition. You can refer to this list when speaking with the doctor and/care team on how to move forward.

You're all set

Other popular topics

IMPORTANT SAFETY INFORMATION

GATTEX may cause serious side effects, including:

The most common side effects of GATTEX in adults include:

What should I tell my healthcare provider before using GATTEX?

What is GATTEX?

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When it comes to managing your child’s SBS, you feel*: 