Patient Questionnaires

Dr Chahaya Gauci — Colorectal & General Surgeon

Before we start

These short questionnaires measure how bowel control problems affect you. Your answers help Dr Gauci track your symptoms over time — for example before and after treatment. There are no right or wrong answers.

This information is collected by Dr Chahaya Gauci (Suite 4, 29–33 Orlando Street, Coffs Harbour NSW) to guide your care, and forms part of your medical record, stored securely in line with the Privacy Act 1988 (Cth) and NSW health records law. You can skip any question. Questions: (02) 6651 6211.
Please enter your name and date of birth.

Which questionnaires?

Tick the ones Dr Gauci or the rooms asked you to complete. If you're not sure, tick the first one.

Please tick at least one questionnaire.

Bowel control score

For each type of leakage, choose how often it happens to you.

1. Accidental leakage of solid stool
2. Accidental leakage of liquid stool
3. Accidental loss of gas (wind)
4. I need to wear a pad because of leakage
5. Leakage changes the way I live my life
Please answer every question on this page (choose "Never" if it doesn't happen).

St Mark's score

Thinking about the past four weeks.

1. Accidental leakage of solid stool
2. Accidental leakage of liquid stool
3. Accidental loss of gas (wind)
4. Leakage changes the way I live my life
5. Do you need to wear a pad or plug for bowel leakage?
6. Do you take constipating medicines to control leakage? e.g. loperamide (Imodium, Gastro-Stop)
7. When you feel the urge to open your bowels, can you hold on for 15 minutes?
Please answer every question on this page.

Quality of life — part 1

1. In general, would you say your health is:

Due to accidental bowel leakage…

For each statement, choose how much of the time it is a concern for you because of accidental bowel leakage. If it concerns you for a different reason, choose "Doesn't apply".

Quality of life — part 2

Due to accidental bowel leakage…

Choose how much you agree or disagree with each statement because of accidental bowel leakage. If it applies to you for a different reason, choose "Doesn't apply".

During the past month, have you felt so sad, discouraged, hopeless, or had so many problems that you wondered if anything was worthwhile?

Bowel function after rectal surgery

The aim of this questionnaire is to assess your bowel function after rectal surgery. Please choose only one answer for each question. It may be difficult to select only one answer, as symptoms can vary from day to day — please choose the answer that best describes your usual daily life. If you have recently had an infection affecting your bowel function, please do not take this into account.

1. Do you ever have occasions when you cannot control your flatus (gas)?
2. Do you ever have any accidental leakage of liquid stool?
3. How often do you empty your bowels?
4. Do you ever have to empty your bowels again within one hour of the last bowel emptying?
5. Do you ever have such a strong urge to empty your bowels that you have to rush to the toilet?
Please answer every question on this page.

Your health today

For each area, choose the statement that best describes your health today.

Test build: the official EQ-5D-5L question wording is licensed and will appear here once the practice's EuroQol registration is complete.
How good or bad is your health today? 0 = the worst health you can imagine, 100 = the best health you can imagine
Slide to answer
Please answer every question and move the health slider.

Thank you — all done

Your answers have been scored and turned into a summary for Dr Gauci.

Note text preview (staff use)








Dr Chahaya Gauci MBBS MS FRACS · Suite 4, 29–33 Orlando Street, Coffs Harbour NSW 2450 · (02) 6651 6211

If you are unwell right now with severe pain, heavy bleeding or fever, call 000 or go to your nearest emergency department.