General Feeling
Lethargy(Alasya)YesNo Weakness (Dorbalya)YesNo Body Ache( Sharir -peeda)YesNo Appetite(Bhukh)YesNo Sleep (Nidra)YesNo
Abdominal Problem
Any tenderness in abdomenYesNo Abdominal painYesNo Abdominal DistentionYesNo Abdominal TenesmusYesNo Feeling of Gaseous sounds in abdomenYesNo
Bowel Movement
Constipation – Hard ,Pellet type or ribbon type DiarrhoeaYesNo
Stool related problems
Volume – small volume or large volume
Consistency
WateryYesNo Formed or semisolid FroathyYesNo
Frequency
Number of stool in day / night
Mucous
Passage of mucous mixed with stool or separately Passage along with stoolYesNo Passage only Mucous without stool (Mucoid Stool)
Tenesmus
Stool with Tenesmus or without Tenesmus
Smell
Foul smell or any pungent smell
Blood
Blood in stool in traces or mixed with stool or no blood
Digital Evacuation
Any history of digital Evacuation YesNo
Is there any feeling of incomplete Evacuation ?
YesNo
Any problem of Farting
Past Medical History
Any History of Chronic or Long standing Constipation / Diarrhoea or Dysentery Is there any history of GIT or Systemic problems
Present Medication
For any health problem
Family History
Single/MarriedYesNo Father /Mother and Siblings and their problems regarding GIT
Social History
Smoking/ Alcohol/any addiction
Mental Faculty
Psychiatric – Behaviour Normal mood Dysphoric Mood Nervous/ Anxious DepressionYesNo Any type of stressYesNo Lack of interest in surroundingsYesNo
Duration of Disease
How long have you been suffering
Any Specific Reason for Onset of This Problem Long standing Diarrhoea or Dysentr Bearing of any long standing mental stress ,Anxiety or Dysphoric mood Any other
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