COALESIA — Medical questionnaire

1. About you

Full name Phone Different WhatsApp number Date of birth Age Country City Language

Other contacts

EmailCaregiver / contact personContact person phone

2. Clinical manifestations

What are you experiencing now? *

What bothers you most? *

When did this start? * How often does this happen? *

3. Warning signs

Do you have any of these now? *

If there is blood, black stool, severe pain, repeated vomiting, fainting, inability to drink, or no gas/stool, seek urgent medical care.

4. Bowel movements

How often do you have a bowel movement? * What is your stool usually like? *

5. Nutrition and weight

How is your appetite? * How much are you eating compared with usual? * Is it difficult to swallow? * Have you lost weight without trying? *

Current weight, kg

Is there food that makes you feel worse?

6. Past history

Which conditions have doctors told you that you have?

Have you had abdominal surgery?

What are you taking now or have already tried?

Which medicines are you taking now?

7. Documents and submit

If you have test results or medical reports, add them

What else would you like to ask or tell the doctor?

Important information — details

Support terms

I consent to processing my personal and medical information for a remote consultation and preparation of preliminary recommendations. I have read and understand the capabilities and limitations of remote preliminary assessment described above. I understand that I independently decide whether to use a recommendation received through the platform. Before starting, changing, or stopping treatment or using any medication or other product, I undertake to consult my own treating physician. I separately consent to anonymous use of photographs and clinical history for educational or scientific materials. Refusal does not affect medical support.

After submission, the information will be stored in the center’s protected administrative system.

Gastrointestinal health, nutrition and metabolic changes