FECAL INCONTINENCE QUALITY OF LIFE SCALE(FIQOL)

FECAL INCONTINENCE QUALITY OF LIFE SCALE(FIQOL)

Version 06.08.23
Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
1. In general, would you say your health is*

ExcellentVery GoodGoodFairPoor
2. For each of the items, please check the appropriate box indicating how much of the time the issue is a concern for you, due to accidental bowel leakage.

Due to accidental bowel leakage:*

	Most of the Time	Some of the Time	A Little of the Time	None of the Time
a. I am afraid to go out
b. I avoid visiting friends
c. I avoid staying overnight away from home
d. It is difficult for me to get out and do things like going to a movie or to church
e. I cut down on how much I eat before I go out
f. Whenever I am away from home, I try to stay near a restroom as much as possible
g. It is important to plan my schedule (daily activities) around my bowel pattern
h. I avoid traveling
i. I worry about not being able to get to the toilet in time
j. I feel I have no control over my bowels
k. I can’t hold my bowel movement long enough to get to the bathroom
l. I leak stool without even knowing it
m. I try to prevent bowel accidents by staying very near a bathroom

3. Due to accidental bowel leakage, indicate the extent to which you
AGREE or DISAGREE with each of the following items.

Due to accidental bowel leakage:*

	Strongly Agree	Somewhat Agree	Somewhat Disagree	Strongly Disagree
a. I feel ashamed
b. I cannot do many of things I want to do
c. I worry about bowel accidents
d. I feel depressed
e. I worry about others smelling stool on me
f. I feel like I am not a healthy person
g. I enjoy life less
h. I have sex less often than I would like to
i. I feel different from other people
j. The possibility of bowel accidents is always on my mind
k. I am afraid to have sex
l. I avoid traveling by plane or train
m. I avoid going out to eat
n. When I go some place new, I specifically locate where the bathrooms are

4. During the past month, have you felt so sad, discouraged, hopeless, orhad so many problems that you wondered if anything was worthwhile?*

Extremely So - To the point that I have just about given upVery Much SoQuite a BitSome - Enough to bother meA Little BitNot at allOther
FECAL INCONTINENCE SEVERITY INDEX (FISI)
For each of the following, please indicate on average how often in the past month you experienced any amount of accidental bowel leakage.

(Check one box per row)

1. Do you ever leak without being aware of it first? If no, go to question #4*

YesNo
2. If yes, was it....

GasLiquidSolid
3. If yes, was it...

Small StainLarge StainPartial Bowel MovementComplete Bowel Movement
4. Do you ever have great urgency (need to have a bowel movement) when you felt you would not make it to the toilet in time to open your bowels? If no, go to #7.*

YesNo
5. If yes, did you actually lose some stool before getting to the toilet?

YesNo
6. If yes, was it...

Small StainLarge StainPartial Bowel MovementLarge or Complete Bowel Movement
7. Do you wear a pad or use a plug of tissue?*

YesNo
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