SIBO Breath Test Intake Form

This form takes approximately 10–15 minutes. It collects your gut history, symptom pattern, and medication history needed to both interpret your SIBO breath test results and confirm you are following the correct preparation protocol.

01Personal Details

Full name

Date of birth

Date completing this form

02Preparation Protocol Confirmation

Preparation failures are the most common cause of uninterpretable SIBO results

Required preparation — confirm you have followed this:

24-hour preparatory diet: no complex carbohydrates, no fermentable foods (see diet sheet)
Fast for minimum 12 hours before the test (water only)
No antibiotics in the 4 weeks prior to testing
No probiotics in the 2 weeks prior to testing
No laxatives or bowel preparations in the 4 weeks prior
No proton pump inhibitors on the morning of the test (if possible)
No smoking, vigorous exercise, or sleep during the test

Have you followed the 24-hour preparatory diet?

Yes — fully Yes — mostly (minor deviations) No — please advise Not yet — completing before test

Any antibiotics in the past 4 weeks?

No Yes — please specify below

Any probiotics in the past 2 weeks?

No Yes — stopped now Yes — still taking

Preparation notes (deviations, concerns, questions)

04Symptom Pattern

Rate each: 0 = absent, 1 = mild/occasional, 2 = significant/frequent

Bloating after eating

Bloating timing: within 90 min

Excessive flatulence

Abdominal pain / cramping

Diarrhoea

Constipation

Alternating bowel habit

Nausea

Worsening on probiotics

Worsening on high-fibre / FODMAP

Fatigue after meals

Brain fog / cognitive symptoms

Predominant bowel pattern

Do symptoms improve significantly when not eating (fasting, liquid-only)?

Yes — clearly better Somewhat No difference Haven't tried

Primary concern / what you most want to understand from this test

Ready to submit?

Stephen will review your intake form and preparation status before your breath test. If there are any preparation concerns he will contact you before you begin the test.

This form is read personally by Stephen Duncan FDN-P. Functional testing is investigative, not diagnostic. If you experience acute abdominal pain or bleeding, contact your GP or attend A&E.

Intake form submitted

Thank you. Stephen will review your form and preparation status. Your breath test kit instructions will follow by email.