Bowel Obstruction Risk Assessment
Please answer the following questions to help assess your risk of bowel obstruction and identify urgent symptoms.
Current Symptoms
When did the symptoms start?
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Do you have abdominal pain?
*
Yes
No
Where is the abdominal pain located?
Please Select
Upper abdomen
Lower abdomen
Left side
Right side
Around the belly button
Diffuse/entire abdomen
Other
How severe is the abdominal pain?
1
2
3
4
5
Do you feel nauseated?
Yes
No
Have you vomited?
Yes
No
If yes, how often have you vomited?
Please Select
Once
2-3 times
4-5 times
More than 5 times
Not applicable
Do you have abdominal bloating or distension?
Yes
No
Are you unable to pass stool?
Yes
No
Are you unable to pass gas?
Yes
No
Relevant Medical History
Have you had prior abdominal or pelvic surgery?
*
Yes
No
Unsure
Do you have a known hernia?
*
Yes
No
Unsure
Which of the following conditions have you been diagnosed with?
Inflammatory bowel disease
Colorectal cancer
Chronic constipation
Previous bowel obstruction
None of the above
Other digestive condition
Have you ever had a bowel obstruction before?
*
Yes
No
Unsure
How often do you usually have constipation?
Please Select
Never
Occasionally
Frequently
Ongoing/Chronic
Unsure
Other relevant medical history
Medications and Intake
Current medicines that may affect bowel motility
Opioid pain medicines
Anticholinergic medicines
Iron supplements
Other medicines that may slow the bowel
None of the above
Other relevant medicines
Able to keep fluids down
*
Yes
No
Sometimes
Dehydration symptoms
Dry mouth
Dark urine
Dizziness
Weakness
Reduced urination
None of these
Appetite compared with usual
Normal
Reduced
Very poor
Unable to eat
Urgency and Red Flags
Severe constant abdominal pain
*
No
Mild
Moderate
Severe
Persistent vomiting
*
No
Occasional
Persistent
Abdominal swelling or bloating
*
No
Mild
Moderate
Severe
No bowel movement or gas for a prolonged period
*
Please Select
Less than 12 hours
12–24 hours
24–48 hours
More than 48 hours
Other urgent warning signs present
Dizziness or fainting
Blood in vomit or stool
Unable to tolerate fluids
Other
Overall urgency level
*
1
2
3
4
5
Submit Assessment
Should be Empty: