Constipation questionnaire

Name:______Date:______

This questionnaire is designed to measure the impact of constipation on your daily life. The questionnaire contains questions about how you feel and how things have been going over the past four weeks. For each question, please circle one number.

The following questions ask you
about your symptoms, to what
extent………. / Not at all / A little bit / Moderately / Quite a bit / Extremely
Have you had stomach or abdominal pains / 1 / 2 / 3 / 4 / 5
Have your felt bloated, to the point of bursting / 1 / 2 / 3 / 4 / 5
Have you felt heavy? / 1 / 2 / 3 / 4 / 5
Have you had flatulence (wind)? / 1 / 2 / 3 / 4 / 5
Have you had pain when opening your bowels or trying to? / 1 / 2 / 3 / 4 / 5
Have you had painful spasms as a result of taking medicine to help open your bowels? / 1 / 2 / 3 / 4 / 5
The next few questions ask you
About the effects of constipation
on your daily life. How much of
the time……… / None of the time / A little of the time / Some of the time / Most of the time / All of the time
Have you felt any physical discomfort? / 1 / 2 / 3 / 4 / 5
Have you had difficulty concentrating (for example, reading, watching television, working)? / 1 / 2 / 3 / 4 / 5
Have you been embarrassed to be with other people? / 1 / 2 / 3 / 4 / 5
Have you been woken at night because of stomach pains? / 1 / 2 / 3 / 4 / 5
Have you been able to wear the clothes that you wanted to wear? / 1 / 2 / 3 / 4 / 5
Have you been eating less and less because you have not been able to open your bowels / 1 / 2 / 3 / 4 / 5
Have you felt the need to open your bowels but not been able to? / 1 / 2 / 3 / 4 / 5
The next few questions ask you
about your feelings. How much of
the time …….. / None of the time / A little of the time / Some of the time / Most of the time / All of the time
Have you felt irritable? / 1 / 2 / 3 / 4 / 5
Have you been upset by your condition? / 1 / 2 / 3 / 4 / 5
Have you felt obsessed by your condition? / 1 / 2 / 3 / 4 / 5
Have you felt stressed by your condition? / 1 / 2 / 3 / 4 / 5
Have you been less confident? / 1 / 2 / 3 / 4 / 5
The next questions ask about how
satisfied you are. To what extent. / Not at all / A little bit / Moderately / Quite a bit / Extremely
Have you been satisfied with how often you open your bowels? / 1 / 2 / 3 / 4 / 5
Have you been satisfied with the regularity with which you open your bowels / 1 / 2 / 3 / 4 / 5
Have you been satisfied with your intestinal transit? / 1 / 2 / 3 / 4 / 5
Have you been satisfied with your treatment? / 1 / 2 / 3 / 4 / 5
The next questions ask you about
your life with constipation. How
much of the time…….. / None of the time / A little of the time / Some of the time / Most of the time / All of the time
Have you been able to live a normal life despite your condition? / 1 / 2 / 3 / 4 / 5
Have you felt in control of your situation? / 1 / 2 / 3 / 4 / 5
Have you been afraid that your condition is getting worse? / 1 / 2 / 3 / 4 / 5
Has your condition affected your sex life? / 1 / 2 / 3 / 4 / 5
Have you felt that your body was not working properly? / 1 / 2 / 3 / 4 / 5

Does constipation affect your life in any ways other that those described in this questionnaire? Yes □ No □

If yes, please describe these effects in the space below:

______

Over the past four weeks, would you say your digestive state was:

Very poorVery good

012345678910