Incontinence Problems Questionaire - Cauda Equina web site - www.oldcity.org.uk/cauda_equina/
To evaluate your problem please print and complete this questionnaire and show it to your doctor or nurse (adapted from Jorge and Wexner, 1993).

1. Consistency of faeces:
 liquid
 semiliquid
 formed/soft
 formed/hard
 hard and dry
2. Type of incontinence:
 evacuatory urgency (have to hurry to toilet)
 faecal soiling
 faecal incontinence
3. Regarding incontinence of:
3a. Gas:
 none
 on movement
 at rest

 never
 rarely (less than 1/month)
 occasionally (1/week - 1/month)
 often (1/day - 1/week)
 always (at least 1/day)
3b. Liquid stool:
 none
 on movement
 at rest

 never
 rarely (less than 1/month)
 occasionally (1/week - 1/month)
 often (1/day - 1/week)
 always (at least 1/day)
3c. Formed stool:
 none
 on movement
 at rest

 never
 rarely (less than 1/month)
 occasionally (1/week - 1/month)
 often (1/day - 1/week)
 always (at least 1/day)

Bowel Problems Questionaire Page 2 of 3

4. Use of pads:
 never
 rarely (less than 1/month)
 occasionally (1/week - 1/month)
 often (1/day - 1/week)
 always (at least 1/day)

 day
 night
 day and night
5. Use of constipating agents (antidiarrhoeals):
type:

frequency:
6. Limitations on daily activities:
 physical (avoiding walks, gym, etc.)
 social (avoiding theatre, visits, etc.)

 never
 rarely (less than 1/month)
 occasionally (1/week - 1/month)
 often (1/day - 1/week)
 always (at least 1/day)
7. Sensation during evacuations:
 present
 absent
8. Previous therapy of faecal incontinence (write Yes or No and add a comment):
diet:

medication:

biofeedback:

operations:

Type:____________________ date: _______

result:____________________
9. Accompanying complaints (write Yes or No and add a comment):
rectal pain:

abdominal distension:

rectal bleeding:

mucous on faeces:

Bowel Problems Questionaire Page 3 of 3

10. Gastrointestinal disorders:
 inflammatory bowel disease
 irritable bowel disease
 malabsorption
 other:
11. Pelvic disorders:
 haemorrhoids
 perianal fistula
 perianal fissure
 rectocoele
 anorectal injury
 prolapse of bladder
 prolapse of uterus
 prolapse of rectum
12. Obstetric history:
number of deliveries:

prolonged deliveries:

episiotomies:

tears:

instrumental delivery:

emergency caesarean:
Page Last Updated: 05 May 2004