Constipation Index Personal InformationName First Last Today's Date MM slash DD slash YYYY Who is your therapist?Jennifer CummingSarah DominguezMichelle WebbKelsey BeachSamantha CragerNicole DeBrieChristina WisdomNo therapist assigned yet / I don't knowObstructive Defecation Subscale1. How often do you experience incomplete bowel movements?* Never [0 point] Occasionally [1 point] Sometimes [2 points] Usually [3 points] Always [4 points] 2. How severe is this symptom for you?* Not at all [0 point] Mild [1 point] Somewhat Severe [2 points] Severe [3 points] Extremely Severe [4 points] 3. How much does this bother you?* Not at all [0 point] A little [1 point] Somewhat [2 points] Very [3 points] Extremely [4 points] Straining/Difficulty having a bowel movement1. How often do you experience this?* Never [0 point] Occasionally [1 point] Sometimes [2 points] Usually [3 points] Always [4 points] 2. How severe is this for you?* Not at all [0 point] Mild [1 point] Somewhat Severe [2 points] Severe [3 points] Extremely Severe [4 points] 3. How much does this bother you?* Not at all [0 point] A little [1 point] Somewhat [2 points] Very [3 points] Extremely [4 points] Colonic Inertia SubscaleThink about when you ARE having difficulty with your bowel habits. During a typical month how many times do you usually have a bowel movement?* N/A I never have difficulty with my bowel movements [1 point] Daily [2 points] A few times per week [3 points] Once a week [4 points] Once every two weeks [5 points] Once per month [6 points] Infrequent bowel movementsInfrequent bowel movements are defined as less than 1 bowel movement every 3 days.1. How often do you experience infrequent bowel movements?* Never [0 point] Occasionally [1 point] Sometimes [2 points] Usually [3 points] Always [4 points] 2. How severe is this symptom for you?* Not at all [0 point] Mild [1 point] Somewhat Severe [2 points] Severe [3 points] Extremely Severe [4 points] 3. How much does this bother you?* Not at all [0 point] A little [1 point] Somewhat [2 points] Very [3 points] Extremely [4 points] Lack of urge to have a bowel movement1. When you lack the urge to have a bowel movement, how severe is this for you?* Not at all [0 point] Mild [1 point] Somewhat Severe [2 points] Severe [3 points] Extremely Severe [4 points] 2. When you lack the urge to have a bowel movement, how much does this bother you?* Not at all [0 point] A little [1 point] Somewhat [2 points] Very [3 points] Extremely [4 points] Pain SubscaleRectal/anal pain due to your bowel movements1. During the last month how severe was the pain in your rectum/anus?* Not at all [0 point] Mild [1 point] Somewhat Severe [2 points] Severe [3 points] Extremely Severe [4 points] 2. Rate the level of your anal/rectal pain at the movement.* No Pain [0 point] Mild [1 point] Somewhat Severe [2 points] Severe [3 points] Extremely Severe [4 points] 3. How much suffering do you experience because of the rectal/anal pain?* None [0 point] Mild [1 point] Somewhat Severe [2 points] Severe [3 points] Extremely Severe [4 points] 4. During the past month, due to your bowel habits, how often have you had bleeding during/after bowel movement?* Never [0 points] Rarely [1 point] Occasionally [2 points] Usually [3 points] Always [4 points]