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| Page | 4/5 | | Date | 31.10.2022 | | Size | 382.84 Kb. | | #88003 |
| Dr.Shruthi-PGDG36-constipationQuestionnaire:
Q1. Have you evacuated in the last 24 hours
Q2. What is the usual consistency of your stool?
Type 1
Type 2
Type 3
Type 4
Type 5
Type 6
Type 7
Q3. Have you made any straining when trying to evacuate in the last 24 hours?
Q4. What was the level of straining in the last 24 hours?
Severe
Moderate
Mild
None
Q5. Do you have any history of anorectal obstruction?
Q6. Do you have any history of incomplete evacuation?
Q7. Do you have any history of abdominal discomfort?
Q8. Do you think you have spent too much time trying to evacuate in the last 24 hours?
Q9. Do you feel like you had to pass a bowel movement but you couldn’t (false alarm)?
Q10. Do you experience rectal burning during or after a bowel movement?
Q11. Rectal bleeding or tearing during or after a bowel movement?
Q13. Incomplete bowel movement, like you didn’t “finish”?
Q14. How do you define your bowel function?
Q15. How much water do you consume per day?
Q16. Do you suffer from any disability that restricts your mobility?
Q17. Do you suffer from tooth aches/ cavities/ gingivitis?
Q18. How is your appetite?
Q19. Do you feel a lack of privacy while using the toilet?
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