Adult Mood and Bowel Daily Questionnaire (first week)

Please complete the following daily questionnaire (along with the food diary) during the first week only:

Today's date


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

1. I felt tense or wound up.

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

3. Worrying thoughts went through my mind.

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

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

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

7. I got sudden feelings of panic.

8. Overall, how stressed did you feel today? (0 = not at all stressed, 10 = extremely stressed).

9. How would you rate your general mood today? (0 = very positive, 10 = extremely negative).

10. How many hours of sleep did you get last night?

11. How often did you experience digestive/gastrointestinal problems (tummy pain, diarrhoea, constipation, etc) today?

12. How many bowel movements did you have today?

13. Referring to the stool chart below, please rate your stool consistency today (next to all that apply, indicate how many times that choice occurred).

Bristol Stool Chart

14. Did you participate in any psychotherapy or counselling sessions today?