Appendix.

Each of these statements or questions below describes symptoms or problems which sometimes occur in patients who have had radiation therapy.

Overall, would you say that you had problems with your bowel function in the past week?	Yes	No
1. In the past week, what is the greatest number of bowel movements you have had in a day? ____________________________
For questions 2–10, circle “yes” or “no” in response to each question.
2. In the past week, have you had a problem causing you to get up at night to have a bowel movement?	Yes	No
3. In the past week, have you had a problem causing you to lose control of your bowel movements?	Yes	No
4. In the past week, have you had a problem causing you to have a bowel movement within 30 minutes of a prior bowel movement?	Yes	No
5. In the past week, have you had to wear protective clothing or a pad in case you lost control of a bowel movement?	Yes	No
6. In the past week, have you had a problem causing you to be unable to tell the difference between stool and gas?	Yes	No
7. In the past week, have you had a problem causing you to have stools that are liquid?	Yes	No
8. In the past week, have you found that once you feel the urge to have a bowel movement, you must do so within 15 minutes to avoid an accident?	Yes	No
9. In the past week, have you had cramping with a bowel movement? If yes, is your cramping: _______ Mild _______ Moderate _______ Severe	Yes	No
10. Do you ever have blood in your bowel movement? If yes, check the description that best describes the amount of blood in your bowel movement: _______ On toilet tissue only _______ Mixed with or coating bowel movement _______ Enough to turn water in toilet bowl red	Yes	No

Adapted from Kozelsky et al (12). Used with permission.