The FODMAP Challenge Pre-SurveyPre Survey FODMAPStep 1 of 3 - Basic Information33%Name:*Email:*Age*18-2930-3940-4950-5960+4. Do you give permission for us to use the information provided in this survey for research purposes? All data used will be de-identified.*YesNo5. Have you ever been formally diagnosed with irritable bowel syndrome or other bowel irregularities?*YesNo6. If YES, which one(s)?IBSIBDCoeliac diseaseBowel cancerOther6. If YES, which one(s)? IBS IBD Coeliac Bowel Cancer7. Have you ever had any other further investigations done in relation to your gut symptoms? Please tick all that applyColonoscopyGastroscopyEndoscopyBiopsyBlood testBreath testSkin prick allergy testingOther allergy testing7. Have you ever had any other further investigations done in relation to your gut symptoms? Please tick all that apply Colonoscopy Gastroscopy Endoscopy Biopsy Blood test8. Have you ever been checked for coeliac disease?YesNo9. How long have you dealt with symptoms of irritable bowl syndrome:Less than 3 months3-6 months6-18 months18 months - 3 years3+ years10. Do you have a family history of (tick any that apply): IBS IBD Coeliac disease Bowel cancer None of the above11. What is your stool normally like?*Separate hard lumps, like nutsSausage-like but lumpyLike a sausage but with cracks in the surfaceLike a sausage or snake, smooth and softSoft blobs with clear-cut edgesFluffy pieces with ragged edges, a mushy stoolWatery, no solid pieces11. What is your stool when you experience bowel symptoms?*Separate hard lumps, like nutsSausage-like but lumpyLike a sausage but with cracks in the surfaceLike a sausage or snake, smooth and softSoft blobs with clear-cut edgesFluffy pieces with ragged edges, a mushy stoolWatery, no solid pieces12. How many bowel movements do you have per day?*Less than 11-23-45 or more13. Do you use fibre supplements?*YesNoIf yes, what do you take?How many bowel movements do you have per day without laxatives or aids (e.g. fibre supplements)?Less than 11-23-45 or moreHow many bowel movements do you have per day with laxatives to aid the movement (e.g. fibre supplements)?Less than 11-23-45 or more14. Have you recently taken antibiotics?*YesNo15. Are you on any regular medications? Which ones?*16. If you are female do you experience these symptoms only during your menstrual cycle and at no other times?*YesNoNo, I'm Male17. Do you ever suffer from fatigue/tiredness?*NeverSome of the timeMost of the timeAll of the time18. Do you suffer from stress?*NeverSome of the timeMost of the timeAll of the timeSection AThe following questions ask you about your abdominal and bowel symptoms. When we use the word abdomen we mean belly/tummy. Some of the questions ask about passing a stool. By this we mean going to the toilet for a reason other than to urinate (pass water). All of these questions refer to the last 4 weeks. This portion of the survey is included with thanks to Andrea Roalfe, Lesley Roberts and Sue Wilson of the Department of Primary Care and General Practice, University of Birmingham, Edgbaston, Birmingham1. During the last 4 weeks, how often have you had discomfort or pain in your abdomen?*All of the timeMost of the timeA good bit of the timeSome of the timeA little of the timeNone of the time2. How often have you been troubled with loose, mushy or watery bowel motions during the last 4 weeks?All of the timeMost of the timeA good bit of the timeSome of the timeA little of the timeNone of the time3. How often during the last 4 weeks have you been troubled with diarrhoea?*All of the timeMost of the timeA good bit of the timeSome of the timeA little of the timeNone of the time4. During the last 4 weeks how often have you been troubled by hard bowel motions?*All of the timeMost of the timeA good bit of the timeSome of the timeA little of the timeNone of the time5. During the last 4 weeks how often have you felt the need to strain to pass a motion (stool)?All of the timeMost of the timeA good bit of the timeSome of the timeA little of the timeNone of the time7. During the last 4 weeks how often did you experience pain or discomfort in your abdomen after eating?All of the timeMost of the timeA good bit of the timeSome of the timeA little of the timeNone of the time8. How often has you abdominal pain prevented you from sleeping, or woken you during the night during the last 4 weeks?*All of the timeMost of the timeA good bit of the timeSome of the timeA little of the timeNone of the time9. During the last 4 weeks how often have you leaked or soiled yourself?*All of the timeMost of the timeA good bit of the timeSome of the timeA little of the timeNone of the time10. How often during the last 4 weeks have you suffered from a feeling of urgency (feeling that you must immediately rush to the toilet to pass a stool)?All of the timeMost of the timeA good bit of the timeSome of the timeA little of the timeNone of the time11. How often have you passed mucus or slime in your stools over the last 4 weeks?All of the timeMost of the timeA good bit of the timeSome of the timeA little of the timeNone of the timeSection BThe next set of questions relate to quality of life, and how irritable bowel syndrome may have impacted on your symptoms. Thank you to researchers at Queens University in Canada for allowing us to use the IBS-36 QoL Questionnaire to evaluate participant quality of life in The FODMAP Challenge1. In the past 2 months have you been afraid to eat out because of food causing bowel symptoms? 0 never, 6 always Leave blank if not applicable.Please enter a number from 0 to 6.2. In the past 2 months have you felt angry as a result of your bowel symptoms? 0 never, 6 always Leave blank if not applicable.Please enter a number from 0 to 6.3. In the past 2 months did you need to go suddenly when you had a bowel movement? 0 never, 6 always Leave blank if not applicable.Please enter a number from 0 to 6.4. In the past two months did your bowel symptoms interfere with your relationship/children/partner 0 never, 6 always Leave blank if not applicable.Please enter a number from 0 to 6.5. In the past 2 months did you avoid foods that you like because you were afraid that they might cause bowel symptoms? 0 never, 6 always Leave blank if not applicable.Please enter a number from 0 to 6.6. In the past two months did your bowel symptoms interfere with being able to do well at work/school/usual daily activities? 0 never, 6 always Leave blank if not applicablePlease enter a number from 0 to 6.7. In the past 2 months have you felt tearful or discouraged as a result of you bowel symptoms? 0 never, 6 always Leave blank if not applicable.Please enter a number from 0 to 6.8. In the past 2 months did you feel that your family/friends thought your symptoms were not real? (0 never, 6 always) Leave blank if not applicable.Please enter a number from 0 to 6.9. In the past 2 months how often, while participating in pleasure or sport activities did you have to stop because of your bowel symptoms? 0 never, 6 always. Leave blank if not applicablePlease enter a number from 0 to 6.10. In the past 2 months have you felt worried or anxious about never feeling better? 0 never, 6 always Leave blank if not applicable.Please enter a number from 0 to 6.11. In the past 2 months did you miss work/school/usual daily activities because of your bowel problem? 0 never, 6 always Leave blank if not applicable.Please enter a number from 0 to 6.12. In the past 2 months did your bowel symptoms interfere with being able to concentrate? 0 never, 6 always. Leave blank if not applicable.13. In the past 2 months have you felt alone or isolated from your family because of bowel symptoms? 0 never, 6 always Leave blank if not applicablePlease enter a number from 0 to 6.14. In the past 2 months were you embarrassed because of your bowel symptoms? 0 never, 6 always Leave blank if not applicablePlease enter a number from 0 to 6.15. In the past 2 months were you troubled by pain in your abdomen? 0 never, 6 always Leave blank if not applicable.Please enter a number from 0 to 6.16. In the past 2 months were you afraid that your bowel symptoms were getting worse? 0 never, 6 always Leave blank if not applicablePlease enter a number from 0 to 6.17. In the past 2 months were you troubled y bowel movements that were difficult/hard to pass? 0 never, 6 always Leave blank if not applicable.Please enter a number from 0 to 6.18. In the past 2 months did you check your diet from the previous day trying to find foods that may cause bowel symptoms? 0 never, 6 always Leave blank if not applicable.Please enter a number from 0 to 6.19. In the past 2 months did you avoid travelling due to worry about bowel symptoms? 0 never, 6 always Leave blank if not applicable.Please enter a number from 0 to 6.20. In the past 2 months did your bowel problems shorten the length of time you could work each day? 0 never, 6 always Leave blank if not applicable.Please enter a number from 0 to 6.21. In the past 2 months did your bowel symptoms keep you from sleeping soundly during the night? 0 never, 6 always Leave blank if not applicable.Please enter a number from 0 to 6.22. In the past 2 months were you troubled by loose bowel movements? 0 never, 6 always Leave blank if not applicable.Please enter a number from 0 to 6.23. In the past 2 months did your bowel condition interfere with having sexual relations? 0 never, 6 always Leave blank if not applicable.Please enter a number from 0 to 6.24. In the past 2 months has being bloated troubled you? 0 never, 6 always Leave blank if not applicable.Please enter a number from 0 to 6.25. In the past 2 months did your bowel symptoms interfere with your enjoyment of leisure or sport activities? 0 never, 6 always Leave blank if not applicable.Please enter a number from 0 to 6.26. In the past 2 months was passing large amount of gas a problem? 0 never, 6 always Leave blank if not applicable.27. In the past 2 months were you concerned that your symptoms may be due to cancer? 0 never, 6 always Leave blank if not applicable.Please enter a number from 0 to 6.28. In the past 2 months have you had to delay or cancel going out socially because of your bowel problem? 0 never, 6 always Leave blank if not applicable.Please enter a number from 0 to 6.29. In the past 2 months were you tired in the morning because of your bowel symptoms? 0 never, 6 always Leave blank if not applicable.Please enter a number from 0 to 6.30. In the past 2 months did your bowel symptoms interfere with your desire to have sexual relations with your partner? 0 never, 6 always Leave blank if not applicable.Please enter a number from 0 to 6.31. In the past 2 months has feeling that you need to go to the bathroom even though your bowels are empty troubled you? 0 never, 6 always Leave blank if not applicable.Please enter a number from 0 to 6.32. In the past 2 months did you feel that your doctor/health professionals did not believe that your bowel symptoms were real? 0 never, 6 always Leave blank if not applicable.Please enter a number from 0 to 6.33. In the past 2 months how often do you immediately need to find where the washrooms are when you are in a new place? 0 never, 6 always Leave blank if not applicable.Please enter a number from 0 to 6.34. In the past 2 months did you avoid planning activities ahead of time because you were unsure of how your bowel symptoms would be? 0 never, 6 always Leave blank if not applicable.Please enter a number from 0 to 6.35. In the past 2 months has accidental soiling of your underwear troubled you? 0 never, 6 always Leave blank if not applicable.Please enter a number from 0 to 6.36. In the past 2 months were you late or did you delay work/school/usual daily activities because of your bowel symptoms? 0 never, 6 always Leave blank if not applicable.Please enter a number from 0 to 6.
