IFFGD has developed a Personal Daily Diary that is intended to help you gain a better understanding of your bowel disorder. By keeping a detailed record of diet, medication, stool consistency, frequency, continence, pain, emotional status, and exercise, a clearer understanding may start to emerge for you and/or your physician to determine the best treatment options available to you.
Using The Diary
The objective of using this Daily Diary is to gain a better understanding of your bowel disorder. Use this Personal Daily Diary for 2–4 weeks to help you get the most out of your next doctor visit.
By keeping a detailed record of stool consistency, frequency, continence, pain, diet, medication, emotional status and exercise, a clearer understanding may start to emerge for you and/or your physician to determine the best treatment options available to you.
Find examples of what to record at the bottom of this page.
Name: ____________________
Day of the Week: ____________ Date: ____________
Bowel Symptoms
Evacuation in Toilet
| Time | Stool Description & Symptom |
|---|---|
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
Gas
| Time | Details |
|---|---|
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
Stain/Smear
| Time | Stool Description & Symptom |
|---|---|
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
Incontinent Bowel Movement
| Time | Stool Description & Symptom |
|---|---|
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
Bowel Symptoms Summary
| Number of daytime evacuations: ____________ |
| Number of nighttime evacuations: ____________ |
| Number of stains or smears: ____________ |
| Number of incontinent bowel movements, if any: ____________ |
| Number of protect undergarments used, if any: ____________ |
Pain
| Time | Description & Duration |
|---|---|
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
Emotional Status
| Time | Details |
|---|---|
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
Medications
| Time | Prescription/Over-the-Counter |
|---|---|
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
Diet
Medications
| Time | Prescription/Over-the-Counter |
|---|---|
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
Foods
| Breakfast | Time | Items |
|---|---|---|
| ____________ | ____________________________________ | |
| ____________ | ____________________________________ | |
| ____________ | ____________________________________ | |
| ____________ | ____________________________________ | |
| ____________ | ____________________________________ | |
| Lunch | Time | Items |
| ____________ | ____________________________________ | |
| ____________ | ____________________________________ | |
| ____________ | ____________________________________ | |
| ____________ | ____________________________________ | |
| ____________ | ____________________________________ | |
| Dinner | Time | Items |
| ____________ | ____________________________________ | |
| ____________ | ____________________________________ | |
| ____________ | ____________________________________ | |
| ____________ | ____________________________________ | |
| ____________ | ____________________________________ |
Beverages
| Time | Items |
|---|---|
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
Exercise
| Time | Exercise Type |
|---|---|
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
| ____________ | ____________________________________ |
Women
| Menstrual cycle; ovulation; menstruation |
|---|
| ____________________________________ |
| ____________________________________ |
Examples
| Descriptions | Examples |
|---|---|
| Stool Description | Loose; diarrhea; formed; hard, pellet-like; ribbon-shaped |
| Symptoms | Incomplete evacuation; strong urge; straining; incontinent; stain/smear |
| Gas | Belching; flatus |
| Pain | Abdominal cramping; lower intestinal cramping; pain on either side of abdomen; tenderness (tender when touched); rectal pain (sharp dull, burning; feels like a hard object is in rectum; cramping sensation in rectum) |
| Emotional Status How do you feel? Why? |
Fine; happy; relaxed; anxious; nervous; sad; unhappy, depressed; fatigued; tired (wake up tired, wake up during the night) – mentally tired, physically tired |
| Stressors | Daily obligations; employment; school; family; social; travel; shopping; medical appointments; illness; injury; trauma; surgery; personal/intimate |
| Medications | Prescription/over-the-counter including herbs or supplements; and Dosage |
| Women | Menstrual cycle; ovulation; menstruation |
| Food List everything, be detailed. |
Fruits; vegetables; dairy products; meat; fish; poultry; breads (whole grain, etc); pasta; dessert; condiments (salt, pepper, sauces, spices, oils) |
| Beverages | Caffeine; decaffeinated; carbonated; diet/sugar free; alcohol; fruit juices |
| Exercise | List examples: walk, run, bike, swim, aerobic, other; and times |
