Your toilet habits
1. What form of IBD have you been diagnosed with? Please be specific if you can.
Crohn's - Gastroduodenal (Upper)
Crohn's - Jejunoileitis
Crohn's - Ileitis
Crohn's - Ileocolitis
Crohn's - Colitis
Crohn's - Perianal
Ulcerative Colitis - Left-sided
Ulcerative Colitis - Pancolitis
Ulcerative Colitis - Proctosigmoiditis
Ulcerative Colitis - Proctitis
I don't know
2. Do you consider yourself to currently be
In a severe flare
In a mild flare
Symptom free but not in remission
In clinical remission
3. How many times did you go to the toilet (stool) yesterday?
4. Is this:
Normal for me
Above average for me
Below average for me
5. What is the consistency of your stool?
Blood and mucous only
Watery stool with blood
Watery stool with mucous
Watery stool with blood and mucous
Watery stool only
Loose stool with blood
Loose stool with mucous
Loose stool with blood and mucous
Loose stool only
Formed stool with blood
Formed stool with mucous
Formed stool with blood and mucous
Formed stool only
Hard stool with blood
Hard stool with mucous
Hard stool with blood and mucous
Hard stool only
6. Are you experiencing any urgency to go to the toilet?
I'm currently incontinent all the time
I'm currently incontinent some of the time
Feeling of urgency but can hold on
7. How long are you spending on the toilet each time you go?
Less than 5 minutes
More than 60 minutes
8. Did you wake in the night last night to go to the toilet?
Your previous toilet habits
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