Adult Mood and Bowel Weekly Questionnaire

Please complete the following weekly questionnaire:

Todays date

Date

Date you started taking the powder (if known)

Date

1. How many packages of powder do you have left?

2. Which week are you in? (If known)

3. Did you take your powder every day this past week?

4. How many days did you MISS?

The following questions deal with anxiety and mood. Please choose the rating that most applies to you over the past week.

5. I felt tense or wound up.

6. I got a sort of frightened feeling as if something awful was about to happen.

7. Worrying thoughts went through my mind.

8. I was able to sit at ease and feel relaxed.

9. I got a sort of frightened feeling like butterflies in my stomach.

10. I felt restless, as if I had to be on the move.

11. I got sudden feelings of panic.

12. Overall, how stressed did you feel this week? (0 = not at all stressed, 10 = extremely stressed).

13. Overall this week, how would you rate your general mood? (0 = very positive, 10 = extremely negative).

14. On average, how many hours of sleep did you get each night this week?

Have you been bothered by stomach ache or pain in the last week? (stomach ache refers to all aches and pains in your stomach or belly)

Have you been bothered by heartburn during the past week? (by heartburn we mean a burning pain or discomfort behind the breastbone in your chest)

Have you been bothered by acid reflux during the past week? (by acid reflux we mean regurgitation or flow of sour or bitter fluid into your mouth)

Have you been bothered by hunger pains in the stomach or belly in the past week? (this hollow feeling in the stomach is associated with the need to eat between meals)

Have you been bothered by nausea during the past week? (by nausea we mean a feeling of wanting to be sick)

Have you been bothered by rumbling in your stomach or belly during the past week? (rumbling refers to vibrations or noises in the stomach)

Has your stomach felt bloated during the past week? (feeling bloated refers to swelling in the stomach or belly)

Have you been bothered by burping during the past week? (burping refers to bringing up air or gas through the mouth)

Have you been bothered by passing gas or flatus during the past week? (passing gas refers to the release of air or gas from the bowels)

Have you been bothered by constipation during the past week? (constipation refers to a reduced ability to empty the bowels)

Have you been bothered by diarrhea during the past week? (diarrhea refers to frequent loose or watery stools)

Have you been bothered by loose stools during the past week? (if your stools have been alternately hard and loose, this question only refers to the extent you have been bothered by the stools being loose)

Have you been bothered by hard stools during the past week? (if your stools have been alternately hard and loose, this question only refers to the extent you have been bothered by the stools being hard)

Have you been bothered by an urgent need to have a bowel movement during the past week? (this urgent need to open your bowels makes you rush to the toilet)

When going to the toilet during the past week, have you had the feeling of not completely emptying your bowel? (the feeling that after finishing a bowel movement, there is still some stool that needs to be passed)

16. On average, how many bowel movements did you have each day this past week?

17. Referring to the stool chart below, please rate your stool consistency over the past week (note how often you had each type of poop on the line beside it: never, sometimes, often, all the time).

Bristol Stool Chart

18. Did you participate in any psychotherapy or counselling sessions this week?

Physical Activity

How would you classify your physical activity for the past week? (select one)