IBS Triaging Questionnaire

Once you have completed this questionnaire our Dietitian will review your answers and you will be triaged into an appropriate group session or clinic with the dietitian.

Please only complete this questionnaire if you have been referred by the GP practice – only those who have been referred by the GP practice will be triaged.

IBS Triaging Questionnaire

IBS Triaging Questionnaire

If you are human, leave this field blank.

NHS Number:

When did your symptoms first start?

Have you identified a cause for the start of your symptoms? (e.g. use of antibiotics, foreign travel, stressful event?)

Please detail any significant past medical history:

Medication

Medication Description:

Dosage:

Frequency:

Medication Description:

Dosage:

Frequency:

Medication Description:

Dosage:

Frequency:

Medication Description:

Dosage:

Frequency:

Medication Description:

Dosage:

Frequency:

Please detail any allergies you have:

If you were to rate your average stress level over the last month on a scale between 1 and 5 (1 = no stress and 5 = very stressed), what number would you give?

1

2

3

4

5

Do you notice that your gastro-intestinal symptoms change, as your stress level changes?

Please detail your symptom history

Abdominal pain:

None

Mild

Moderate

Severe

Frequency (times per week):

Abdominal bloating / distention:

None

Mild

Moderate

Severe

Frequency (times per week):

Excessive flatulence / wind:

None

Mild

Moderate

Severe

Frequency (times per week):

Stomach gurgling:

None

Mild

Moderate

Severe

Frequency (times per week):

Nausea:

None

Mild

Moderate

Severe

Frequency (times per week):

Urgency to open bowels:

None

Mild

Moderate

Severe

Frequency (times per week):

Incomplete evacuation (feeling like you still need to pass stool after opening your bowels):

None

Mild

Moderate

Severe

Frequency (times per week):

Acid reflux / Heartburn:

None

Mild

Moderate

Severe

Frequency (times per week):

Tiredness / fatigue:

None

Mild

Moderate

Severe

Frequency (times per week):

Please tick which image your stools look like the most (it could be more than one option):

Type 1 - Separate hard lumps, like nuts (hard to pass)

Type 2 - Sausage-shaped but lumpy

Type 3 - Like a sausage but with cracks on the surface

Type 4 - Like a sausage or snake, smooth and soft

Type 5 - Soft blobs with clear-cut edges (passed easily)

Type 6 - Fluffy pieces with ragged edges, a mushy stool

Type 7 - Watery, no solid pieces. Entirely Liquid

How many times do you open your bowels?

Over 7 times per day

4-6 times per day

2-3 times per day

Once a day

Once every 2-3 days

Once every 4-6 days

Less than once per week

What colour are your stools?

Colour 1

Colour 2

Colour 3

Colour 4

Colour 5

Colour 6

Colour 7

Colour 8

Do you ever pass blood in your stool?

Yes

No

Do you ever pass mucus in your stool?

Yes

No

Are there any foods that you have noticed make your symptoms worse?

Have you already made any changes to your diet (e.g. excluding wheat, reducing caffeine). Have any of these changes helped your symptoms?

Have you tried probiotics?

Yes

No

How many meals do you eat a day and are these at consistent times?

How many portions of fruit & vegetables do you eat in a day? (80g = 1 portion)

How many units of alcohol do you drink per week?

Which fluids do you normally drink each day e.g. tea, coffee, energy drinks, fizzy drinks, milky drinks, water, squash, juice) and in what quantity?

Have you seen a dietitian in the past? If yes, please give a brief description as to what was discussed:

Any other comments:

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