In the Past Week

Not Suffered at All

Hardly Suffered

Slightly Suffered

Moderately Suffered

Very Suffered

Extremely Suffered

Insufferable

1)

Have you suffered from stomach pain?

1

2

3

4

5

6

7

2)

Heartburn

1

2

3

4

5

6

7

3)

Acid reflux from the stomach

1

2

3

4

5

6

7

4)

Stomach pain on an empty stomach

1

2

3

4

5

6

7

5)

Nausea

1

2

3

4

5

6

7

6)

Stomach making noise

1

2

3

4

5

6

7

7)

Fullness in the stomach

1

2

3

4

5

6

7

8)

Burp

1

2

3

4

5

6

7

9)

Fart

1

2

3

4

5

6

7

10)

Constipation

1

2

3

4

5

6

7

11)

Diarrhea

1

2

3

4

5

6

7

12)

Loose stool

1

2

3

4

5

6

7

13)

Hard stool (having difficulty to stool)

1

2

3

4

5

6

7

14)

An urgency to defecate

1

2

3

4

5

6

7

15)

Incomplete evacuation

1

2

3

4

5

6

7

16)

Lower abdominal fullness

1

2

3

4

5

6

7

17)

Impatience

1

2

3

4

5

6

7

18)

Light sleep

1

2

3

4

5

6

7

19)

Cold extremities

1

2

3

4

5

6

7

20)

Pimply or rough skin

1

2

3

4

5

6

7