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