Bowel Habit Assessment Form
Please complete this form to help assess your bowel habits and related symptoms for a better understanding of your digestive health.
Full Name
*
First Name
Last Name
Age
*
Gender
*
Male
Female
Other
How often do you usually have a bowel movement?
*
More than 3 times per day
1-3 times per day
Every other day
Less than 3 times per week
Other
Please indicate the usual consistency of your stool using the Bristol Stool Chart below:
*
Type 1: Separate hard lumps, like nuts
Type 2: Sausage-shaped but lumpy
Type 3: Like a sausage but with cracks on its surface
Type 4: Like a sausage or snake, smooth and soft
Type 5: Soft blobs with clear-cut edges
Type 6: Fluffy pieces with ragged edges, mushy
Type 7: Watery, no solid pieces
In the past 4 weeks, how often have you experienced the following symptoms?
*
Rows
Never
Rarely
Sometimes
Often
Always
Urgency to have a bowel movement
1
2
3
4
5
Straining during bowel movements
6
7
8
9
10
Feeling of incomplete emptying
11
12
13
14
15
Abdominal pain or discomfort
16
17
18
19
20
Presence of blood in stool
21
22
23
24
25
Presence of mucus in stool
26
27
28
29
30
Do you use any of the following to help with bowel movements? (Select all that apply)
*
Laxatives
Enemas
Suppositories
No assistance
Other
How would you rate your overall satisfaction with your bowel habits?
*
1
2
3
4
5
How many glasses of water do you drink per day (on average)?
*
How would you describe your typical diet?
*
High fiber (fruits, vegetables, whole grains)
Low fiber
High protein
Mixed/Varied
Other
Please list any medications or medical conditions that might affect your bowel habits (if any):
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