IRRITABLE BOWEL SYNDROME SYMPTOM QUESTIONNAIRE
Date: __/__/____
ESTIMATED TIME: 10’
EPIDEMIOLOGICAL INFORMATION
1. Grade:
2. Sector:
3. Age:
4. Gender: male female 5. Marital status: married single divorced 6. Father’s occupation:
7. Mother’s occupation:
8. I live:
i. Alone
ii. With one or more roomates iii. With my parents
iv. With my partner 9. My residence is:
i. My own home
ii. Rented accommodation iii. Provided by my Service iv. Place of hospitality
10. Have you ever been diagnosed with IBS?
Yes No
11. Do you suffer from any chronic disease? If yes, which one?
Yes No
12. Have you suffered from gastroenteritis the past 6 months?
Yes No
13. Regarding cigarette smoking:
i. No smoking
ii. Used to smoke (... cigarettes/day ... years) iii. I smoke (... cigarettes/day ... years)
14. I take medication for (including laxatives):
DIET:
INITIAL INFORMATION:
1. Hight: Weight:
2. How many days a week do you have...:
SEVEN 5 3 1 NEVER
BREAKFAST LUNCH DINNER SNACKS
3. Have you ever visited a dietician?
Yes No 4. For females: Is your menstruation normal?
Yes No 5. How often do you excersise?
7 days/week 5 days/week 3 days/week 1 days/week never
6. Do you have any known food allergy?
Yes (Define which) No
FOOD FREQUENCY QUESTIONNAIRE
How many times per week do you consume the following foods?
1. Red meat (beef, pork, lamp etc.) …...
2. Chicken/Turkey...
3. Fish/seafood...
4. Cold cuts...
5. Fast-Food...
6. Eggs...
7. Dairy products...
8. Fruits/Juices...
9. Vegetables...
10. Pasta...
11. Legumes...
12. Potatoes...
13. Bakery products...
14. Cereals...
15. Pies, croissants, donuts etc...
16. Sauces...
17. Nuts...
18. Sweets, cakes...
19. Chocolate...
20. Alcohol (glasses per week):
i. Wine...
ii. Beer...
iii. White drinks...
1. Cooking way (numerate per frequency- 1=most often):
a) I cook
b) Frozen cooked meal
c) Buy already cooked meal d) Another person cooks in my house e) I eat in the military camp restaurant ANXIETY ESTIMATION QUESTIONS
1. How many hours do you sleep?
i. More than 8 h ii. Less than 8 h
2. When I was younger than 12 years old I experienced:
i) Parents’ divorce
ii) Death of a close family member iii) Extreme financial difficulty iv) Serious illnes/surgery
v) Abuse
vi) Mental ilness of any parent vii) Parent alcoholism
viii) Domestic violence
3. Durig the last 6 months I felt significant emotional stress due to:
a. Parents’ divorce
b. Death of a close family member
c. Family person deployment d. Divorce
e. Financial difficulties
f. Failure in an important objective g. Unpleasant family environment h. Something else...
Answer the questions below, using a number according to the scale :
1 2 3 4 5
Not at all A little Moderately A lot Very much
1. How much are you affected emotionally by the fact of a possible reduction of your salary and your financial instability?....
2. Does your career development induce more anxiety?...
3. Does the possibility of an unfavourable trasfer to another center/city affect your mood?...
4. How much are you affected emotionally by the specialisation that you are going to follow? ...
5. Do you feel depressed in your working environment?...
6. How important do you think that your job is?...
7. Do the responsibilities in your job position induce anxiety?...
HADS
1. I feel tense or 'wound up':
a. Most of the time b. A lot of the time
c. From time to time, occasionally d. Not at all
2. I still enjoy the things I used to enjoy:
a. Definitely as much b. Not quite so much c. Only a little
d. Hardly at all
3. I get a sort of frightened feeling as if something awful is about to happen:
a. Very definitely and quite badly b. Yes, but not too badly
c. A little, but it doesn't worry me d. Not at all
4. I can laugh and see the funny side of things:
a. As much as I always could
b. Not quite so much now c. Definitely not so much now d. Not at all
5. Worrying thoughts go through my mind:
a. A great deal of the time b. A lot of the time
c. From time to time, but not too often d. Only occasionally
6. I feel cheerful:
a. Not at all b. Not often c. Sometimes d. Most of the time
7. I can sit at ease and feel relaxed:
a. Definitely b. Usually c. Not Often d. Not at all
8. I feel as if I am slowed down:
a. Nearly all the time b. Very often
c. Sometimes d. Not at all
9. I get a sort of frightened feeling like 'butterflies' in the stomach:
a. Not at all b. Occasionally c. Quite Often d. Very Often
10. I have lost interest in my appearance:
a. Definitely
b. I don't take as much care as I should c. I may not take quite as much care d. I take just as much care as ever 11. I feel restless as I have to be on the move:
a. Very much indeed b. Quite a lot
c. Not very much d. Not at all
12. I look forward with enjoyment to things:
a. As much as I ever did b. Rather less than I used to c. Definitely less than I used to d. Hardly at all
13. I get sudden feelings of panic:
a. Very often indeed b. Quite often
c. Not very often d. Not at all
14. I can enjoy a good book or radio or TV program:
a. Often b. Sometimes
c. Not often d. Very seldom ROME IV based IBS Diagnosis 1. In the last 3 months, how often did
you feel abdominal pain?
i. Never
ii. Less than one day per month iii. One day per month
iv. 2 to 3 days per month v. One day per week
vi. More than one day per week vii. Every day
2. Female only: Does this pain occur only during your menstruation?
1.Yes 2. No 3. I am in menopause
3. How long do you fell this pain? 1.last 6 months 2.more than 6 months 4. Is there an association between
abdominal pain and defeacation?
Never/rare
Sometimes
Often
Most of times
Always 5. Do you have bowel movements more
often, since this pain started? Never/rare
Sometimes
Often
Most of times
Always 6. Do you have bowel movements more
seldom, since this pain started? Never/rare
Sometimes
Often
Most of times
Always 7. Is your stool looser, since this pain
started? Never/rare
Sometimes
Often
Most of times
Always 8. Is your stool harder, since this pain
started? Never/rare
Sometimes
Often
Most of times
Always 9. During the last 3 months, how often
do you have stool like separate hard lumps?
Never/rare
Sometimes
Often
Most of times
Always 10. During the last 3 months, how often
do you have mushy/liquid stool? Never/rare
Sometimes
Often
Most of times
Always 11. I have visited a doctor for these
symptoms and I receive therapy Yes No
12. Is there any family history of these conditions;
i. Colorectal cancer ii. Celiac disease
iii. Inflammatory Bowel Disease (Crohn Disease, Ulcerative Colitis) 13. Have you received any antibiotics
recently?
Yes No 14. Did you lose weght unintentionally? Yes No 15. Did you see any blood during
defeacation?
Yes No 16. Do your symptoms awake you at night Yes No