IBS Survey - thank you for taking a time it is very much appreciated
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1
. Are you male or female?
Are you male or female?
Male
Female
2
. How old are you?
How old are you?
16-24
25-34
35-44
45-54
55-64
65+
3
. Have you been diagnosed? With:
Have you been diagnosed? With:
IBS
IBD
Other intestinal disease
None
n/a
4
. Which symptoms do you suffer from?
Which symptoms do you suffer from?
abdominal pain
diarrhoea
constipation
painful constipation
painful constipation with diarrhoea accompanied by abdominal pain
swelling (distension) of the abdomen with wind
unpredictable, erratic bowel actions varying from day to day
indigestion (dyspepsia)
none of those
5
. Please tick all food products which makes your symptoms worse:
Please tick all food products which makes your symptoms worse:
wheat (bread, cereals, etc.. )
dairy foods (milk, cheese, etc..)
peanuts
non-citrus fruits
sugar and substitutes
fatty foods (including takeaways)
spicy foods(including takeaways)
vegetables (cabbage, broccoli, onions, etc.)
pulses (beans, peas, lentils)
none of those
Other (please specify)
6
. Do your symptoms interfere with your social life (e.g. going out with friends)?
Do your symptoms interfere with your social life (e.g. going out with friends)?
no
n/a
yes
if yes, please give brief details
7
. Do you work?
Do you work?
Yes
No
8
. Have you ever felt disadvantages because of your symptoms (e.g. when applying for a job, making friends etc..)?
Have you ever felt disadvantages because of your symptoms (e.g. when applying for a job, making friends etc..)?
No
n/a
Yes
If yes (please give brief details)
9
. Which factors trigger your symptoms the most?
Which factors trigger your symptoms the most?
Diet
Emotional stress
Hormones
n/a
Other (please specify)
10
. Would you be willing to be contacted again in order to confidentially discuss your condition?
Would you be willing to be contacted again in order to confidentially discuss your condition?
no
n/a
yes
if yes, please provide contact details below e.g. email, phone.
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