The following questions are designed to measure the impact that constipation has had on your daily life over the past 2Â weeks. For each question, please check one box. | |||||
---|---|---|---|---|---|
 | Not at all - 1 | A little bit - 2 | Moderately - 3 | Quite a bit - 4 | Extremely - 5 |
The following questions ask about your symptoms related to constipation. During the past 2 weeks, to what extent or intensity have you… | |||||
 1. Felt bloated to the point of bursting? |  |  |  |  |  |
 2. Felt heavy because of your constipation? |  |  |  |  |  |
The next few questions ask about how constipation affects your daily life. During the past 2 weeks, how much of the time have you… | |||||
 3. Felt any physical discomfort? |  |  |  |  |  |
 4. Felt the need to have a bowel movement but not been able to? |  |  |  |  |  |
 5. Been embarrassed to be with other people? |  |  |  |  |  |
 6. Been eating less and less because of not being able to have bowel movements? |  |  |  |  |  |
The next few questions ask about how constipation affects your daily life. During the past 2 weeks, to what extent or intensity have you… | |||||
 7. Had to be careful about what you eat? |  |  |  |  |  |
 8. Had a decreased appetite? |  |  |  |  |  |
 9. Been worried about not being able to choose what you eat (for example, at a friend’s house)? |  |  |  |  |  |
 10. Been embarrassed about staying in the bathroom for so long when you were away from home? |  |  |  |  |  |
 11. Been embarrassed about having to go to the bathroom so often when you were away from home? |  |  |  |  |  |
 12. Been worried about having to change your daily routine (for example, traveling, being away from home)? |  |  |  |  |  |
The next few questions ask about your feelings related to constipation. During the past 2 weeks, how much of the time have you… | |||||
 13. Felt irritable because of your condition? |  |  |  |  |  |
 14. Been upset by your condition? |  |  |  |  |  |
 15. Felt obsessed by your condition? |  |  |  |  |  |
 16. Felt stressed by your condition? |  |  |  |  |  |
 17. Felt less self-confident because of your condition? |  |  |  |  |  |
 18. Felt in control of your situation? |  |  |  |  |  |
The next questions ask about your feelings related to constipation. During the past 2 weeks, to what extent or intensity have you… | |||||
 19. Been worried about not knowing when you are going to be able to have a bowel movement? |  |  |  |  |  |
 20. Been worried about not being able to have a bowel movement? |  |  |  |  |  |
 21. Been increasingly bothered by not being able to have a bowel movement? |  |  |  |  |  |
The next questions ask about your life with constipation. During the past 2 weeks, how much of the time have you… | |||||
 22. Been worried that your condition will get worse? |  |  |  |  |  |
 23. Felt that your body was not working properly? |  |  |  |  |  |
 24. Had fewer bowel movements than you would like? |  |  |  |  |  |
The next questions ask about your degree of satisfaction related to constipation. During the past 2 weeks, to what extent or intensity have you been… | |||||
 25. Satisfied with how often you have a bowel movement? |  |  |  |  |  |
 26. Satisfied with the regularity of your bowel movements? |  |  |  |  |  |
 27. Satisfied with the time it takes for food to pass through the intestines? |  |  |  |  |  |
 28. Satisfied with your treatment? |  |  |  |  |  |