IBS Severity Index (fillable) - Maysie Tift, M.A., LMFT

IBS Severity Index

Name *

Please base your answers on the last 10 days including today *

I understand

1(a). In the last 10 days, have you suffered from abdominal (tummy) pain? *

1(b). If yes, how severe was your abdominal pain? Please indicate a number from 0 to 100, with 0 meaning “no pain” and 100 meaning “very severe”? *

1(c). Please enter the number of times that you had the pain in the last 10 days. For example, if you enter 4, it means that you had pain 4 out of 10 days. *

2(a). Do you currently suffer from abdominal distention (bloating, swollen or tight tummy) (*Women, please ignore distention related to your period) *

2(b). If yes, how severe was your abdominal distention/tightness? Please indicate a number from 0 to 100, with 0 meaning “no distention” and 100 meaning “very severe” *

3. How dissatisfied are you with your bowel habits? Please indicate a number from 0 to 100, with 0 meaning “very happy” and 100 meaning “very unhappy” *

4. Please indicate how much abdominal pain or discomfort  or altered bowel habits are affecting or interfering with your life in general. Please indicate a number from 0 to 100, with 0 meaning “not at all” and 100 meaning “completely” *

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