English (Australia) - UCLA SCTC GIT 2.0 Questionnaire
English (Australia) - UCLA SCTC GIT 2.0 Questionnaire
English (Australia) - UCLA SCTC GIT 2.0 Questionnaire
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In the past 1 week, have you noticed your<br />
stools becoming…<br />
(TICK ONE RESPONSE FOR EACH<br />
QUESTION)<br />
Yes 1 No 0<br />
31. … harder <br />
CONSTIPATION<br />
In the past 1 week, how often …<br />
32.<br />
(TICK ONE RESPONSE FOR EACH<br />
QUESTION)<br />
No 1-2 3-4 5-7<br />
Days 0 Days 1 Days 2<br />
… were you constipated or unable to<br />
empty your bowels <br />
33. … did you have hard stools <br />
34.<br />
… did you have pain while passing<br />
your stools <br />
1/4= 0.25<br />
2/4= 0.50<br />
3/4= 0.75<br />
4/4= 1.0<br />
5/4= 1.25<br />
6/4= 1.50<br />
7/4= 1.75<br />
Days 3<br />
8/4= <strong>2.0</strong><br />
9/4= 2.25<br />
10/4= 2.5<br />
SCORE C=<br />
Thank you for completing the questionnaire<br />
To be completed by the doctor<br />
TOTAL SCORE= Reflux<br />
_____<br />
+ Distension/Bloating _____<br />
+ Faecal Soilage _____<br />
+ Diarrhoea _____<br />
+ Social functioning _____<br />
+ Emotional wellbeing _____<br />
TOTAL SCORE=<br />
(_____) /6= _____<br />
REMEMBER: CONSTIPATION SCORE IS NOT INCLUDED IN CALCULATION<br />
OF TOTAL SCORE<br />
C=Constipation; D=Diarrhoea; D/B=Distension/Bloating; EM=Emotional wellbeing;<br />
R=Reflux; SF=Social functioning; S=Faecal soilage<br />
© Dinesh Khanna, MD, MS 5<br />
<strong>UCLA</strong> <strong>SCTC</strong> <strong>GIT</strong> <strong>2.0</strong>
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