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 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?

Please detail your symptom history

Abdominal pain:
Abdominal bloating / distention:
Excessive flatulence / wind:
Stomach gurgling:
Urgency to open bowels:
Incomplete evacuation (feeling like you still need to pass stool after opening your bowels):
Acid reflux / Heartburn:
Tiredness / fatigue:

Please tick which image your stools look like the most (it could be more than one option):
How many times do you open your bowels?
IBS Colours
What colour are your stools?
Do you ever pass blood in your stool?
Do you ever pass mucus in your stool?

Have you tried probiotics?