1. The frequency of bowel movements is:
A. 2 or more times a day
B. Once daily
C. Almost every day
D. 2-3 times each week
E. Maybe once a week
2. Which of the following do I experience (check all that apply):
A. Burping or belching
B. Indigestion
C. Bowel gas
D. Bloat
E. Frequent abdominal pain
F. Occasional pain
3. Do I use any of the following to help my bowel movements (check all that apply):
A. Over the counter products
B. Herbs or teas
C. Suppositories
D. Enemas
E. Fiber or fiber supplements
4. Is my bowel movement:
A. Hard and lumpy
B. Like marbles or pellets
C. Soft and unformed
D. Formed, easy to eliminate
E. Skinny and flat
F. Splatty and loose
5. How much time do I spend on the toilet:
A. 30 minutes or more
B. Maybe 5 minutes
C. I'm in and out in a minute or two
D. I hurry to find a toilet when I gotta go
E. I know where every bathroom is because of urgency.
6. When I travel, my bowels:
A. They are just the same
B. They hardly ever move. I wait until I get home.
C. I take something (laxatives, herbs or enemas) to have a bowel movement.
D. Traveling gives me diarrhea.
7. I take medicine for:
A. Blood pressure
B. Diabetes
C. Pain
D. Anxiety or depression
E. Sleep
F. Other medication, please state what condition you have.
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