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Symptom Diary

IFFGD has developed a Personal Daily Diary that is intended to help you gain a better understanding of your bowel disorder. By keeping a detailed record of diet, medication, stool consistency, frequency, continence, pain, emotional status, and exercise, a clearer understanding may start to emerge for you and/or your physician to determine the best treatment options available to you.

Using The Diary

The objective of using this Daily Diary is to gain a better understanding of your bowel disorder. Use this Personal Daily Diary for 2–4 weeks to help you get the most out of your next doctor visit.

By keeping a detailed record of stool consistency, frequency, continence, pain, diet, medication, emotional status and exercise, a clearer understanding may start to emerge for you and/or your physician to determine the best treatment options available to you.

See the examples in the table here for ideas on what to record.

Name: ____________________ 
Day of the Week
: ____________  Date: ____________

Bowel Symptoms

Evacuation in Toilet

Time

Stool Description & Symptom

_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________

Gas

Time

Details

_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________

Stain/Smear

Time

Details

_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________

Incontinent Bowel Movement

Time

Stool Description & Symptom

_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________

Bowel Symptoms Summary

Number of daytime evacuations: _____
Number of nighttime evacuations: _____
Number of stains or smears: _____
Number of incontinent bowel movements, if any: _____
Number of protect undergarments used, if any: _____

Pain

Time

Description & Duration

_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________

Emotional Status

Time

Details

_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________

Medications

Time

Prescription/Over-the-Counter

_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________

Diet

Foods

Breakfast

Time

Items

  _________ _______________________________________________________
  _________ _______________________________________________________
  _________ _______________________________________________________
  _________ _______________________________________________________
  _________ _______________________________________________________
Lunch

Time

Items

  _________ _______________________________________________________
  _________ _______________________________________________________
  _________ _______________________________________________________
  _________ _______________________________________________________
  _________ _______________________________________________________
Dinner

Time

Items

  _________ _______________________________________________________
  _________ _______________________________________________________
  _________ _______________________________________________________
  _________ _______________________________________________________
  _________ _______________________________________________________

Beverages

Time

Items

_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________

Exercise

Time

Exercise Type

_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________

Women

Menstrual cycle; ovulation; menstruation

_______________________________________________________
_______________________________________________________

Examples

Descriptions Examples
Stool Description Loose; diarrhea; formed; hard, pellet-like; ribbon-shaped
Symptoms Incomplete evacuation; strong urge; straining; incontinent; stain/smear
Gas Belching; flatus
Pain Abdominal cramping; lower intestinal cramping; pain on either side of abdomen; tenderness (tender when touched); rectal pain (sharp dull, burning; feels like a hard object is in rectum; cramping sensation in rectum)
Emotional Status
How do you feel? Why?
Fine; happy; relaxed; anxious; nervous; sad; unhappy, depressed; fatigued; tired (wake up tired, wake up during the night) – mentally tired, physically tired
Stressors Daily obligations; employment; school; family; social; travel; shopping; medical appointments; illness; injury; trauma; surgery; personal/intimate
Medications Prescription/over-the-counter including herbs or supplements; and Dosage
Women Menstrual cycle; ovulation; menstruation
Food
List everything, be detailed.
Fruits; vegetables; dairy products; meat; fish; poultry; breads (whole grain, etc); pasta; dessert; condiments (salt, pepper, sauces, spices, oils)
Beverages Caffeine; decaffeinated; carbonated; diet/sugar free; alcohol; fruit juices
Exercise List examples: walk, run, bike, swim, aerobic, other; and times

 

Last modified on January 17, 2013 at 09:28:40 AM