DIARRHEA ASSESSMENT
This assessment will help your health care providers advise you on the treatment for the diarrhea you are having. Please answer every question the best that you can.
1. How often do you NORMALLY have a bowel movement when not having diarrhea? _______per day or _______per week
2. How many times per day are you having bowel movements NOW? _______
3. Are you running a fever of 100.5°F or greater? _________ yes _______ no
4. Are you having any abdominal pain?
If yes, please describe:______________
5. Is there any blood in your bowel movements? _________yes _______no
If yes, do you have any bleeding hemorrhoids? _______yes _______no
6. Have you recently taken any laxatives or stool softeners? _______yes _______no
7. Do any medicines seem to make the diarrhea worse? _______yes _______no
If yes, please list_______________
8. Does the diarrhea seem to be related to eating? _______yes _______no
If yes, please describe_____________________
9. When did the diarrhea start? _____________________
10. Did the diarrhea start suddenly _______ or gradually____________?
11. Describe your bowel movements (check all that apply):
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