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Bowel questionnaire

This document is for your own purpose only. It is to make you feel prepared for questions you might receive from the healthcare professional. The answers can hopefully facilitate the conversation and help you to remember what you would like to raise and discuss.

Please answer the questions. The answers will not be stored unless you klick the Save button at the bottom of the form.

Symptoms

My problems and symptoms are:







I have sought help for this before

Bowel emptying/toilet habits

I need to pressure or assist with my fingers during defecation?
Any experience of bowel accidents?
I am using incontinence aid
I am taking laxatives, fiber intake or similar on a regular basis
According to the picture below, my stool usually looks like type
Bristol Scale Type 1
Bristol Scale Type 2
Bristol Scale Type 3
Bristol Scale Type 4
Bristol Scale Type 5
Bristol Scale Type 6
Bristol Scale Type 7

Medications

Medical history

Daily life


Examples: Always check for toilets before going somewhere, planning my day after toilet visits, staying home.

Other

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