Personal Information

    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

    YesNo

    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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