Self-Reported Constipation in Patients with Advanced Cancer: A Preliminary Report

. Author manuscript; available in PMC: 2014 Jan 1.

Published in final edited form as: J Pain Symptom Manage. 2012 Jul 25;45(1):10.1016/j.jpainsymman.2012.01.009. doi: 10.1016/j.jpainsymman.2012.01.009

Rome Questionnaire – Constipation Module

1. In the last 3 months, how often did you have discomfort or pain anywhere in your abdomen?	⓪ Never → ① Less than one day a month ② One day a month ③ Two to three days a month ④ One day a week ⑤ More than one day a week ⑥ Every day	*Skip to question 9*
2. For women: Did this discomfort or pain occur only during your menstrual bleeding and not at other times?	⓪ No ① Yes ② Does not apply because I have had the change in life (menopause) or I am a male
3. Have you had this discomfort or pain 6 months or longer?	⓪ No ① Yes
4. How often did this discomfort or pain get better or stop after you had a bowel movement?	⓪ Never or rarely ① Sometimes ② Often ③ Most of the time ④ Always
5. When this discomfort or pain started, did you have more frequent bowel movements?	⓪ Never or rarely ① Sometimes ② Often ③ Most of the time ④ Always
6. When this discomfort or pain started, did you have less frequent bowel movements?	⓪ Never or rarely ① Sometimes ② Often ③ Most of the time ④ Always
7. When this discomfort or pain started, were your stools (bowel movements) looser?	⓪ Never or rarely ① Sometimes ② Often ③ Most of the time ④ Always
8. When this discomfort or pain started, how often did you have harder stools?	⓪ Never or rarely ① Sometimes ② Often ③ Most of the time ④ Always
9. In the last 3 months, how often did you have fewer than three bowel movements (0-2) a week?	⓪ Never or rarely ① Sometimes ② Often ③ Most of the time ④ Always
10. In the last 3 months, how often did you have hard or lumpy stools?	⓪ Never or rarely ① Sometimes ② Often ③ Most of the time ④ Always
11. In the last 3 months, how often did you strain during bowel movements?	⓪ Never or rarely ① Sometimes ② Often ③ Most of the time ④ Always
12. In the last 3 months, how often did you have a feeling of incomplete emptying after bowel movements?	⓪ Never or rarely ① Sometimes ② Often ③ Most of the time ④ Always
13. In the last 3 months, how often did you have a sensation that the stool could not be passed, (i.e., blocked), when having a bowel movement?	⓪ Never or rarely ① Sometimes ② Often ③ Most of the time ④ Always
14. In the last 3 months, how often did you press on or around your bottom or remove stool in order to complete a bowel movement?	⓪ Never or rarely ① Sometimes ② Often ③ Most of the time ④ Always
15. In the last 3 months, how often did you have difficulty relaxing or letting go to allow the stool to come out during a bowel movement?	⓪ Never or rarely ① Sometimes ② Often ③ Most of the time ④ Always
16. Did any of the symptoms of constipation listed in questions 9-15 above begin more than 6 months ago?	⓪ No ① Yes
17. In the last 3 months, how often did you have loose, mushy or watery stools?	⓪ Never or rarely ① Sometimes ② Often ③ Most of the time ④ Always