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Functional Systems Analysis Questionnaire
The following questions are important to help identify potential factors that may be contributing to your condition. Please indicate the most appropriate number on all questions below. (0 meaning the least/never to 3 meaning the most/always).
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First Name and Last Initial
*
Feeling that bowels do not empty completely
*
0
1
2
3
Lower abdominal pain relieved by passing stool or gas
*
0
1
2
3
Alternating constipation and diarrhea
*
0
1
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3
Diarrhea
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0
1
2
3
Constipation
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0
1
2
3
Hard, dry, or small stool
*
0
1
2
3
Coated tongue or “fuzzy” debris on tongue
*
0
1
2
3
Pass large amount of foul-smelling gas
*
0
1
2
3
More than 3 bowel movements daily
*
0
1
2
3
Use laxatives frequently
*
0
1
2
3
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25
