Stool Consistency Assessment Questionnaire
Please complete this questionnaire to help assess your bowel habits and stool consistency for health evaluation purposes.
Full Name
*
First Name
Last Name
Age
*
Gender
*
Male
Female
Other
How often do you typically have a bowel movement?
*
More than 3 times a day
1-3 times a day
Every other day
Less than 3 times a week
Other
Please assess the consistency of your stool using the following descriptions (based on the Bristol Stool Form Scale):
*
Rows
Never
Rarely
Sometimes
Often
Always
Type 1: Separate hard lumps, like nuts
1
2
3
4
5
Type 2: Sausage-shaped but lumpy
6
7
8
9
10
Type 3: Like a sausage but with cracks on its surface
11
12
13
14
15
Type 4: Like a smooth, soft sausage or snake
16
17
18
19
20
Type 5: Soft blobs with clear-cut edges
21
22
23
24
25
Type 6: Fluffy pieces with ragged edges, mushy stool
26
27
28
29
30
Type 7: Watery, no solid pieces
31
32
33
34
35
Do you experience any of the following symptoms with your bowel movements? (Select all that apply)
*
Abdominal pain
Bloating
Urgency
Straining
Blood in stool
Mucus in stool
None of the above
Other
How would you rate the usual ease of passing your stool?
*
Very difficult
1
2
3
4
Very easy
5
1 is Very difficult, 5 is Very easy
Have you recently changed your diet or started any new medications that could affect your bowel movements?
*
Yes
No
If yes, please specify the changes (diet or medications):
Do you have any relevant medical conditions (e.g., IBS, Crohn's disease, ulcerative colitis)?
Is there anything else you would like to share about your bowel habits or stool consistency?
Submit Assessment
Should be Empty: