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Irritable Bowel Syndrome

IBS Symptom Checklist

With an all-consuming condition like IBS, a simple visit to the doctor can be quite daunting. He or she may ask all kinds of questions, many of which can seem personal or embarrassing. You may not feel up to answering them then and there.

The IBS questionnaire helps you answer some of these questions in advance, in your own time, in the comfort of your own home. It also acts as a useful reminder of questions you want to ask and comments you want to make.

Fill out the form, print it out and take it along with you when you go to see your doctor:

1) Which of the following symptoms do you suffer from (tick all that apply):
 Abdominal cramps
 Bloating
 Constipation
 Diarrhoea
 Nausea
 Anxiety
 Tiredness/lethargy
2) Do the above symptoms recur? If so, how frequently?
 Yes - Frequency:
 No
3) If you suffer from abdominal cramps, how bad are they on a scale from one to five (five being the worst)?
 1  2  3  4  5 
4) Does the pain subside after a bowel movement?
 Yes  No
5) When you have a bowel movement, do you have a feeling of incomplete evacuation?
 Yes  No
6) Do you have feelings of urgency in going to the toilet?
 Yes  No
7) Do you locate the nearest toilet wherever you go?
 Yes  No
8) When you have a bowel movement, do you have to strain?
 Yes  No
9) How would you describe your stools:
 Hard, lumpy and painful to pass
 Solid but soft and easy to pass
 Watery and difficult to control
10) When did you first experience the above symptoms(eg: 5 years ago)?
11) Can you relate it to any big event in your life (change of job, house, divorce, bereavement)?
12) Can you relate it to any change in your eating habits?
 Yes  No
13) Does stress appear to bring it on?
 Yes  No
14) Does it usually strike during menstruation (women)?
 Yes  No
15) Do you experience pain during intercourse (women)?
 Yes  No
16) Are you on medication for other reasons than the above symptoms?
 Yes  No
17) If yes to the above, please list them.
18) Are you taking anything to relieve the above symptoms?
 Yes  No
19) If yes to the above, please list them and state whether they have worked.
20) Are the symptoms disruptive to your life? If so, in what ways?
 Yes  No
Comments:
Questions:

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