Please indicate how you perceive your stool frequency (Based on the last 3 days)

□ Normal

□ 1–2 more stools than normal

□ 3–4 more stools than normal

□ 5 + more stools than normal

Please indicate the severity of your rectal bleeding (Based on the last 3 days)

□ No blood seen

□ Streaks of blood seen with stools for half of the time

□ Obvious blood with stool most of the time

□ Blood alone passed (with no stool)