Bowel Care Intake Form
Please complete this form to help us assess and plan your bowel care needs.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Date of Intake
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you have any of the following medical conditions?
*
Spinal cord injury
Multiple sclerosis
Parkinson’s disease
Diabetes
None of the above
Other
How often do you have a bowel movement?
*
Please Select
Daily
Every other day
2-3 times per week
Once a week or less
Other
Please describe your usual stool consistency:
*
Hard
Formed
Loose
Watery
Do you currently experience any of the following symptoms?
*
Constipation
Diarrhea
Fecal incontinence
Bloating
Abdominal pain
None of the above
List any current medications or treatments for bowel care:
Please describe your typical diet and daily fluid intake:
Do you have any known allergies? If yes, please specify:
Have you had any previous bowel surgeries or procedures? If yes, please provide details:
Submit Intake Form
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