Sitting on the toilet survey
Sex
Male
Female
Age
Race: (Label yourself as needed)
Your Home City
How did you find out about us?


What names do you use to refer to your bodily functions when peeing?


What names do you use to refer to your bodily functions when having a bm?


What names do you use to refer to the toilet?


This section will be used to analyze the digestive performance characteristics of the various
shapes and sizes people come in.

My approximate height is:

Excluding my weight, my body's bone structure has a build.

(optional) Please briefly describe yourself

Peeing

How many times a day do you need to pee?(urinate)
1 2 3 4 5 6 7 8-10 more than 10

When I pee, I pee: (amount)
Very Little...........Large Amounts
1 2 3 4 5

My pee is usually (assuming the background below was white)


What time(s) of day do you usually pee?
I have no set time
4am 5a 6a 7a 8a 9a 10a 11a 12 noon 1p 2p 3p
4pm 5p 6p 7p 8p 9p 10p 11p 12 midnight 1a 2a 3a



My aim is bad

Do you pee while taking a shower? yes no
Please tell why or why not.



Having a bm

How often do you need have a bm?



When I have a bm I have:[amount]
(see striped areas in diagram below for comparison)

Small Loads...................Large Loads
 1    2   3   4   5
Toilet coverage area samples


What time(s) of day do you usually have a bm?

I have no set time
4am 5a 6a 7a 8a 9a 10a 11a 12 noon 1p 2p 3p
4pm 5p 6p 7p 8p 9p 10p 11p 12 midnight 1a 2a 3a


Where do you have your bm the most often? i.e. (home, work, bushes, school, etc.)



How long does it usually take?
It takes me to have my bm.


What if any activities do you partake in while sitting on the toilet?


When my BM first starts coming out its consistency usually is:
hard
firm
soft
mushy [barely solid]
runny/liquid

In general, my BM usually is: (Check below)

When starting my BM, I have to push:
1 not at all
2
3
4
5 very hard


I usually start having my bm I sit/squat/etc.


The length of pieces of my bm at the beginning is about:
(see arrow in diagram below for comparison)

Short/lumps...................Long
 1    2   3   4   5
Length comparisons

The thickness of my bm at the beginning is about: (guess below):

The beginning of my BM usually is (check all that apply):
solid, (all on piece)
in a few pieces
loose (a lot of pieces)

smooth lumpy
gassy cramps/stomach ache

pointed floats undigested food

sticky slimy falls apart stringy

In the middle or towards the end of my BM, its consistency becomes:
harder
about the same
a bit softer
mushy [barely solid]
runny/watery

Towards the end of my BM, I have to push:
1 not at all
2
3
4
5 very hard

The length of pieces of my bm toward the end are about:
(see arrow in diagram below for comparison)

Short/lumps...................Long
 1    2   3   4   5
Length comparisons

The thickness of my bm at end (guess below):

(if needed) At the end My BM is:
solid, (all one piece)
in a few pieces
loose (a lot of pieces)

smooth lumpy

gassy cramps/stomach ache
pointed floats undigested food

sticky slimy falls apart stringy



When I'm having a BM I have it

I pee while having my BM


My BM comes out:
1 slowly.............5 very fast
1 2 3 4 5


I strain loudly
Ipush or poke myself to help me go

I usually have to peices when I go.

I fidget when I need to:
pee1 2 3 4 5
have a bm 1 2 3 4 5


when I start to feel the need to pee I:


when I start to feel the need to have a bm I:

I usually feel the need to have a bm:

No set time
when I wake up
after eating
after work/school
after exercise or physical activity
before bed
during the night


I am constipated or have trouble having a bm:

I get softer than normal BMs or diarrhea:

(optional) Do any particular foods give you diarrea or unusually soft BMs?


What names do you use to refer to unusually soft BMs or diarea?



I can't hold it and pee on myself:

I can't hold it and have a bm on myself:




I pull my pants down
just far enough to go
to my thighs
to my knees
down to my ankles
I take them off

When using the toilet to pee, at home my preferred position is: (check up to three)
sitting standing squatting bending over I get up on my toes

When having a bm, at home my preferred position is: (check up to three)
sitting standing squatting bending over I get up on my toes


I sit on the seat while
peeing in public
having a BM in public
(if you sit on the seat:)

If I have to use a public restroom, portable toilet etc and I don't feel the facilities are clean;
when I have to pee, I:
when I have to have a bm, I:

(optional) For the above questions please tell us why or why not



I am a parent, guardian or care for children. [boys and girls age 3-13] (baby sitting/day care, foster care, sleep overs, etc.)
I have younger brothers and sisters or other children who live or stay with me.


I have used a store fitting/changing room to:
pee
have a BM

(optional) For the above questions please tell what happened.




None/not at all.............Lots/very much
I make (blank) noise when: peeing1 2 3 4 5
having a bm 1 2 3 4 5
My BMs are messy 1 2 3 4 5
I clean myself well after: peeing1 2 3 4 5
having a bm 1 2 3 4 5


When I clean myself I use:

I wipe front to back, back to front, digging in or I dab myself clean.

I wipe while sitting, bending, standing, raising one leg squatting, reaching between my legs.


I place the toilet paper roll in the holder so that the paper comes off of:

Toilet paper positioned over the front the front side of the roll

the back side of the roll (drops down by the wall)

(optional) If there is no toilet paper I:




Never.....................Always
I look in the toilet after peeing 1 2 3 4 5
I look in the toilet after having a bm 1 2 3 4 5
After I have a bm, there is (blank) smell 1 2 3 4 5
I wash my hands after: peeing1 2 3 4 5
having a bm1 2 3 4 5
I Flush after: peeing1 2 3 4 5
having a bm1 2 3 4 5
I feel fully emptied out after a BM 1 2 3 4 5

I flush the toilet to cover the noise when I have a bm


I usually need (blank) flushes after having a bm.
One, Two, Three or more
1 2 3 or more


Thinking about your eating habits on average
what do you eat most often for the following meals?

Breakfast:
Lunch:
Dinner:
I usually eat:


Cereal/Grains
   Dry cereal oatmeal, grits, rice, etc.
Hot food:
   Eggs, sausage, biscuits etc.
Snack foods:
   chips, candy, cookies, donuts
Fast food:
   McDonalds, Burger King, etc
Fruit Left overs Coffee
I usually eat:


Square meal
   Home cooked, cafeteria,
   TV dinners, entrees etc.
Snack foods:
   chips, candy, cookies, donuts
Fast food:
   McDonalds, Taco Bell,
   White Castle etc.
Fruit and or salad
I usually eat:


Square meal
   Home cooked, cafeteria,
   TV dinners, entrees etc.
Snack foods:
   chips, candy, cookies, donuts
Fast food:
   McDonalds, Taco Bell,
   White Castle etc.
Fruit and or salad


My diet contains:

Fats, salts, and spices
1 never.............5 always


Hot or Spicy foods
1 2 3 4 5

Greasy, fatty, oily or fried foods
1 2 3 4 5


Plant products
1 never.............5 always


Fruit: Apples, pears, oranges, etc.
1 2 3 4 5

Green vegetables: salad, spinach, collards etc.
1 2 3 4 5

Grains/beans: rice, pasta, sorghum, millet etc.
1 2 3 4 5


Meat, corn syurp, and milk
1 never.............5 always


Meat, poultry, fish and meat like products
1 2 3 4 5

Desserts: sweets, candy, etc.
1 2 3 4 5

Dairy products: Ice cream, milk
1 2 3 4 5


Laxatives and supplements
1 never.............5 always


Vitamans, nutritional supplements or weight loss products
1 2 3 4 5

I Take Laxatives
1 2 3 4 5


I usually drink:(choose up to 4)

sodas, pop, cola or syrupy juice like drinks
coffee
energy drinks (Red Bull, Monster, Amp)
sports drinks (Gatorade, Powerade, Propel etc.)
milk
water
natural fruit juice
alcohol
tea (all kinds)



(This question applies to work, camping/hiking/racing, picnics, carnivals, concerts, sporting events,
and public facilities such as: parks, swimming pools, beaches, lakes and roadway rest areas)


I am often outdoors when there are few or inadequate washroom facilities
never.................always
1 2 3 4 5



I have peed outdoors:


I have had a BM outdoors:


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