Does abdominal discomfort or cramping ever accompany bowel movements? Yes 1 No . If so, how often? Input frequency
Have you ever been diagnosed as having dental, gum, mouth, stomach, liver, gallbladder, pancreas, intestinal, or bowel disorder or disease? Yes No.
Have you had or do you have hemorrhoids or varicose veins? Yes No
Do you make a conscious effort to eat a high fiber diet? Yes No
Do you usually pay attention when nature calls? Yes No
Name: Full Name | Week of: Week date range