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The FMS Community I.B.S. Symptom Journal
Fill out the journal daily and present to your health care provider when seeking treatment.
|
Date: ___/___/___ |
Pain | Bloating | Diarrhea | Constipation | Nausea ? |
| Time Symtoms Began: |
____ |
____ a.m?? p.m. |
____ a.m?? p.m. |
____ a.m?? p.m. |
____ a.m?? p.m. |
| Time Symptoms Ended: | ____ a.m?? p.m. |
____ a.m?? p.m. |
____ a.m?? p.m. |
____ a.m?? p.m. |
____ a.m?? p.m. |
| Rate the severity of each symptom: 1/mild 10 severe |
1? 2? 3? 4 5 |
1? 2? 3? 4? 5 6? 7? 8? 9? 10 |
1? 2? 3? 4? 5 6? 7? 8? 9? 10 |
1? 2? 3? 4? 5 6? 7? 8? 9 10 |
1? 2? 3? 4? 5 6? 7? 8? 9? 10 |
| What was I doing when symptoms began? | |||||
| Food Eaten prior to symptoms. | |||||
| Amount of Food Eaten: 1) Less than normal 2) Normal 3) A bit more than normal 4) Excessive amount. |
1 ? 2? 3? 4 |
1? 2? 3 ? 4 | 1? 2? 3 ? 4 | 1? 2? 3 ? 4 | 1? 2? 3 ? 4 |
| Medication tried. | |||||
| Notes: List trigger foods, adverse medication reactions etc. |
Do not try to treat your IBS on your own, over use of laxatives, anti-diarrheals and supplements can cause new health problems.
Contact a health care provider for professional advice.
Please feel free to print off as many copies as you need.