J Leech Nutrition Limited
Integral to your treatment: IBS Symptom Survey
We want to make sure you get the most effective care possible, and that's why you must fill in this essential IBS survey before we begin.
By completing this 5-10 minute survey, you are helping us to understand your symptoms and situation clearly, and also providing data that contributes to IBS and IBD research. We’re pioneering the future of health and nutrition service delivery, and you are a part of that!
We ask you to complete this form now, and we will send you the same form mid-way through your program, at the end of your program, and then 6 months out of your program too. This will allow us to establish the long-term effectiveness of the interventions we use and to inform service improvements in the future (you may also choose to stop participating in the data gathering at the end of your program).
The survey used here includes the IBS-QOL, IBS-WPAI, IBS-PHQ-4 and IBS-SSS, which are all validated tools used for IBS research. Your data will be held securely and will be used to contribute to IBS research, improve clinical practice and improve patient outcomes.
Thank you for helping us make the future of health and dietetics a reality.
Your email address
*
Today's date
*
MM
/
DD
/
YYYY
Your date of birth
*
MM
/
DD
/
YYYY
What is your predominant IBS subtype?
*
Please select a choice
IBS-D (diarrhoea predominant)
IBS-C (constipation predominant)
IBS-M/U (mixed/undefined)
How much do you estimate you spent managing your IBS/digestive issues in the past 6 months (medications, supplements, medical costs etc). A rough estimate is fine.
*
IBS-QOL. Evaluate the 34 statements. (If any statement is not applicable to you, choose option 1 'not at all')
*
Not at all
Slightly
Moderately
Quite a bit
Extremely/A great deal
I feel helpless because of my bowel problems.
1
2
3
4
5
I am embarrassed by the smell caused by my bowel problems.
1
2
3
4
5
I am bothered by how much time I spend on the toilet.
1
2
3
4
5
I feel fat because of my bowel problems.
1
2
3
4
5
I feel like I'm losing control of my life because of my bowel problems.
1
2
3
4
5
I feel my life is less enjoyable because of my bowel problems.
1
2
3
4
5
I feel uncomfortable when I talk about my bowel problems.
1
2
3
4
5
I feel depressed about my bowel problems.
1
2
3
4
5
I feel isolated from others because of my bowel problems.
1
2
3
4
5
I have to watch the amount of food I eat because of my bowel problems.
1
2
3
4
5
Because of my bowel problems, sexual activity is difficult for me.
1
2
3
4
5
I feel angry that I have bowel problems.
1
2
3
4
5
I feel like I irritate others because of my bowel problems.
1
2
3
4
5
I worry that my bowel problems will get worse.
1
2
3
4
5
I feel irritable because of my bowel problems.
1
2
3
4
5
I worry that people think I exaggerate my bowel problems.
1
2
3
4
5
I feel I get less done because of my bowel problems.
1
2
3
4
5
I have to avoid stressful situations because of my bowel problems.
1
2
3
4
5
My bowel problems reduce my sexual desire.
1
2
3
4
5
My bowel problems limit what I can wear.
1
2
3
4
5
I have to avoid strenuous activity because of my bowel problems.
1
2
3
4
5
Because of my bowel problems, I have difficulty being around people I do not know well.
1
2
3
4
5
I feel sluggish because of my bowel problems.
1
2
3
4
5
Long trips are difficult for me because of my bowel problems.
1
2
3
4
5
It is important to be near a toilet because of my bowel problems.
1
2
3
4
5
My life revolves around my bowel problems.
1
2
3
4
5
I worry about losing control of my bowels.
1
2
3
4
5
I fear that I won't be able to have a bowel movement.
1
2
3
4
5
My bowel problems are affecting my closest relationships.
1
2
3
4
5
I feel that no one understands my bowel problems.
1
2
3
4
5
IBS-PHQ-4. Evaluate the following statements.
*
Not at all
Several days
More than half the days
Nearly every day
Over the last 2 weeks, how often have you been bothered by feeling nervous, anxious or on edge?
1
2
3
4
Over the last 2 weeks, how often have you been bothered by not being able to stop or control worrying?
1
2
3
4
Over the last 2 weeks, how often have you been bothered by little interest or pleasure in doing things?
1
2
3
4
Over the last 2 weeks, how often have you been bothered by feeling down, depressed, or hopeless?
1
2
3
4
IBS-WPAI
1) Are you currently employed (working for pay)?
*
No (move to question 5)
Yes
2) During the past seven days, how many hours did you miss from work because of problems associated with your IBS symptoms? Include hours you missed on sick days, times you went in late, left early, etc. because of IBS symptoms.
Number of hours
*
3) During the past seven days, how many hours did you actually work?
Number of hours
*
4) During the past seven days, how much did IBS symptoms affect your productivity while you were working? Think about days you were limited in the amount or kind of work you could do, days you accomplished less than you would like, or days you could not do your work as carefully as usual. If IBS symptoms affected your work only a little, choose a low number. Choose a high number if IBS symptoms affected your work a great deal.
*
Please select a number
0
1
2
3
4
5
6
7
8
9
10
0 = IBS symptoms
had no effect
10 = IBS symptoms completely prevented
on my work
5) During the past seven days, how much did IBS symptoms affect your ability to do your regular daily activities, other than work at a job? By regular activities, we mean the usual activities you do, such as work around the house, shopping, child care, exercising, studying, etc. Think about times you were limited in the amount or kind of activities you could do and times you accomplished less than you would like. If IBS symptoms affected your activities only a little, choose a low number. Choose a high number if IBS symptoms affected your activities a great deal.
*
Please select a number
0
1
2
3
4
5
6
7
8
9
10
0 = IBS symptoms
had no effect
10 = IBS symptoms completely prevented
on my work
IBS-SSS (Symptom Severity Score). Evaluate the statements below.
1a. Do you currently (in the past 10 days) suffer from abdominal (stomach) pain?
*
Choose one
Yes
No - skip to question 3a
1b. How severe was your abdominal (stomach) pain in the past 10 days? (Please indicate a number from 0 to 100, with 0 meaning “no pain” and 100 meaning “very severe pain”)
*
Choose one
0 - no pain
10
20
30
40
50
60
70
80
90
100 - very severe pain
2. Please enter the number of days you had the abdominal pain in the past 10 days. (For example, if you enter 4 it means that you had pain 4 out of 10 days. If you have pain every day, enter 10.)
*
Choose one
0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days
8 days
9 days
10 days
3a. Do you currently (in the past 10 days) suffer from abdominal distention (bloating, swollen or tight stomach)?
Women: Please ignore distention related to your period when answering this question.
*
Choose one
No - skip to question 4
Yes
3b. How severe was your abdominal distention/tightness in the past 10 days? (Please indicate a number from 0 to 100, with 0 meaning “no distention” and 100 meaning “very severe distention”)
*
Choose one
0 - no distention
10
20
30
40
50
60
70
80
90
100 - very severe distension
4. How dissatisfied are you with your bowel functioning in the past 10 days? (Please indicate a number from 0 to 100, with 0 meaning “Not dissatisfied” and 100 meaning “very dissatisfied”)
*
Choose one
0 - Not dissatisfied
10
20
30
40
50
60
70
80
90
100 - very dissatisfied
5. How much did abdominal pain or discomfort or altered bowel functioning affect or interfere with your life in general in the past 10 days? (Please indicate a number from 0 to 100, with 0 meaning “Not at all” and 100 meaning “completely”)
*
Choose one
0 - Not at all
10
20
30
40
50
60
70
80
90
100 - Completely
You have completed all the questions! Phew! Thank you from the team at DietvsDisease!
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