EF Health · MacMurray Clinic DGBI Program

Gut-Brain Intake Form

A psychologically informed intake for gut-brain health support

This form helps your clinician understand you as a whole person — your symptoms, how you have been feeling, and what matters most to you right now. It takes approximately 15–20 minutes to complete.

There are no right or wrong answers. Please respond based on your experience over the past two weeks.

Privacy: Your responses are confidential and will only be accessed by your treating clinician at MacMurray Clinic. This form is not monitored in real time. If you are in crisis, call 111, text or call 1737 (free, 24/7), or go to your nearest emergency department.

Section A

Your Details

Personal and contact information

Full name *

Date of birth *

Email address *

Mobile number

Address

Occupation

Referring clinician

GP name

Emergency contact name

Emergency contact phone

I understand my responses will be kept confidential and used by my treating clinician at MacMurray Clinic. I consent to completing this form. *

Please complete your name, date of birth, email address, and consent before continuing.

Section B

Presenting Concerns

Your symptoms and what has brought you here

Main gut symptoms *

When did symptoms begin?

Current diagnosis (if any)

Current medical care and providers

Main reasons for seeking psychological support

What feels hardest right now?

Please describe your main gut symptoms before continuing.

Section C

Gut-Focused Anxiety

How your gut symptoms relate to anxiety and vigilance

Rate each statement from 0 to 4 based on the past two weeks.

0Not at all

1Slightly

2Moderately

3Very much

4Extremely

Please answer all 10 questions before continuing.

Section D

Emotion Sensitivity

How intensely you experience and respond to emotions

Rate each statement from 1 to 5 based on the past two weeks.

1Strongly disagree

2Disagree

3Neutral

4Agree

5Strongly agree

Please answer all 10 questions before continuing.

Section E

Health Anxiety

How health-related worry affects your daily life

Rate each statement from 0 to 3 based on the past two weeks.

0Not at all

1Occasionally

2Often

3Most of the time

Please answer all 10 questions before continuing.

Section F

Functional Impact

How your symptoms affect your daily life and sense of control

Rate each statement from 0 to 4 based on the past two weeks.

0Not at all

1Slightly

2Moderately

3Very much

4Extremely

Please answer all 4 questions before continuing.

Section G

Clinical Background

Optional — share only what you are comfortable with

Trauma history relevant to your symptoms

Yes No Prefer not to say

Major stressors currently affecting your health

Sleep difficulties

Eating restrictions or fear foods

Relevant history (anxiety, depression, ADHD, trauma, ASD, or other)

Current medications

Previous therapy or psychological support

Your goals for this program

✓

Thank you,

Your intake form has been received. Your clinician will review your profile before your first appointment.

What happens next

Your clinician will review your responses and profile before your first appointment. You will receive a confirmation email shortly. The EF Health program will be tailored to your specific profile.

Important: This form is not monitored in real time and is not for emergencies. If you are in distress, call 111, text or call 1737 (free, 24/7), or go to your nearest emergency department.