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. 2012 Sep 27;4:127–139. doi: 10.2147/DHPS.S26580

Table 4.

Bowel habit questionnaires

(A) Used in the long-term extension study (all questions refer to the 2 weeks preceding the visit)
On how many days did you open your bowels?
On days you opened your bowels how many times did you go to the toilet?
How many days were your bowel movements hard and/or lumpy?
How many days did you have to strain to open bowels?
How many days did you feel your bowels were not fully emptied after a visit to the lavatory?
How many days did you feel your bowel habits affected your life?
If your bowel habits affected your life, overall how much was this effect?
(B) Phase IV study in patients ≥65 years of age
Q1: Did you have to strain to move your bowels?
 No
 Yes
Q2: If yes, how much straining did you have to do? (if no, skip question)
 Acceptable straining
 Too much straining
Q3: What was the usual consistency of your bowel movements? (choose one)
 Separate hard lumps, like nuts (hard to pass)
 Sausage shaped but lumpy
 Like a sausage but with cracks on its surface
 Like a sausage or snake, smooth and soft
 Soft blobs with clear cut edges (passed easily)
 Fluffy pieces with ragged edge, a mushy stool
 Watery, no solid pieces
Q4: How often do you have bowel movements?
 Less often
 Unchanged
 More often
Q5: Do you still: (check one)
 Move your bowels every day
 Move your bowels every other day
 Move your bowels 2 or less times per week
 Other
Q6: Have you had to strain to move your bowels?
 No
 Yes
Q7: If yes, how much straining have you had to do? (if no, skip question)
 Acceptable straining
 Too much straining
Q8: What has been the usual consistency of your bowel movements? (choose one)
 Separate hard lumps, like nuts (hard to pass)
 Sausage shaped but lumpy
 Like a sausage but with cracks on its surface
 Like a sausage or snake, smooth and soft
 Soft blobs with clear cut edges (passed easily)
 Fluffy pieces with ragged edge, a mushy stool
 Watery, no solid pieces
Q9: Has the change in your bowel habits affected or interfered with your life in general? (check one)
 Yes, in a bad way
 Not at all
 Yes, in a good way
Q10: How much has the change in your bowel habits affected or interfered with your life in general? (check one)
 Very little
 Moderately
 Quite a lot
 Very much