Murrumbidgee Local Health District



Date: ___/___/_____ Please email to: MLHD-WWRRH-MetabolicObesityService@health..au or fax: 02 6933 9125Dear ____________________Can you could please complete this short questionnaire about your gastrointestinal symptoms during the last week. The explanation below will help you best describe the severity. If there are any questions please don’t hesitate to ask your GP or contact the Metabolic Obesity Service on Mob: 0436 680 198 or email: MLHD-WWRRH-MetabolicObesityService@health..au Severity scaleItems will be judged using a 5 point scale. Only one response per item0 = No problemNo problem1 = Mild problem Can be ignored when you don’t think about it 2 = Moderate problem Cannot be ignored, but does not influence daily activities 3 = Severe problem Influencing your concentration on daily activities4 = Very severe problem Markedly influences your daily activities1. Burning sensation in the oesophagus, belching and regurgitation of acid into the oesophagus (tube joining mouth to stomach)?No problem?Mild?Moderate?Severe?Very severe2. Dysphagia (difficulty swallowing)?No problem?Mild?Moderate?Severe?Very severe3. Fullness (feeling of stomach filled to capacity without relation to prior food intake)?No problem?Mild?Moderate?Severe?Very severe4. Early satiety (stomach is overfilled soon after starting to eat, unrelated to the quantity of food taken, so that food cannot be finished)?No problem?Mild?Moderate?Severe?Very severe5. Postprandial pain or discomfort (upper abdominal symptoms start or get worse after meals)?No problem?Mild?Moderate?Severe?Very severe6. Epigastric pain/upper abdominal pain (pain below the ribs, below the sternum/pain noticeable in upper abdomen)?No problem?Mild?Moderate?Severe?Very severe7. Retrosternal discomfort (unpleasant feeling behind the breastbone)?No problem?Mild?Moderate?Severe?Very severe8. Pain or discomfort prior to defecation?No problem?Mild?Moderate?Severe?Very severe9. Difficulty defecating (straining or incomplete evacuation of the bowel)?No problem?Mild?Moderate?Severe?Very severe10. Constipation (reduced frequency of bowel movements, hard or lumpy stools)?No problem?Mild?Moderate?Severe?Very severe11. Loose stools (soft, or liquid stool)?No problem?Mild?Moderate?Severe?Very severe12. Incontinence (inability to control stool)?No problem?Mild?Moderate?Severe?Very severe13. Urgency to defecate ?No problem?Mild?Moderate?Severe?Very severe14. Diarrhoea (increase in stool frequency, frequently associated with watery loose stool)?No problem?Mild?Moderate?Severe?Very severe ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download