Sex Male Female	Age 5-9 10-13 14-17 18-21 22-25 26-30 31-35 36-40 40-50 50-60 60+	Race: (Label yourself as needed)
Your Home City		How did you find out about us?

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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?

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

My approximate height is:
choose one 4 feet 4 inches and below (132 centimeters) 4 feet 6 inches (137 centimeters) 4' 8" (142 cm) 4' 10" (147 cm) 5' 0" (152 cm) 5' 2" (157 cm) 5' 4" (162 cm) 5' 6" (167 cm) 5' 8" (172 cm) 5' 10" (177 cm) 6' 0" (182 cm) 6' 2" (187 cm) 6' 4" (192 cm)and above.
Excluding my weight, my body's bone structure has a choose one heavy moderate light very light build.

(optional) Please briefly describe yourself

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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.

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Having a bm

How often do you need have a bm?
Click here to Choose One: once every daytwice a daythree times a dayfour times a dayfive times a daymore than five times a dayonce a weektwice a weekevery few daysevery other day


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



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 From: Less than a minute 1-2 minutes 3-5 minutes 5-10 minutes 10-15 minutes 15-20 minutes 20-30 30-45 45-one hour longer than an hour To: Less than a minute 1-2 minutes 3-5 minutes 5-10 minutes 10-15 minutes 15-20 minutes 20-30 30-45 45-one hour longer than an hour 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 choose one before as soon as shortly after a while after 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


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)

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smooth lumpy

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gassy cramps/stomach ache

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pointed floats undigested food

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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


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)

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smooth lumpy

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gassy cramps/stomach ache

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pointed floats undigested food

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sticky slimy falls apart stringy

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When I'm having a BM I have it Choose one all at once almost continuously in one or two separate loads in several separate loads in lots of separate loads

I pee while having my BM Choose one never all at once before having my BM all at once when my BM starts all at once after I finish my BM almost continuously several times during my BM before and again during 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 Choose one I can't tell 1 2 3 4 5 6 7-8 9-15 15-20 20+ to Choose one I can't tell 1 2 3 4 5 6 7-8 9-15 15-20 20+ 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:
click to choose one need to go right away can wait a little while to go can comfortably hold it for a while can hold it until much later

when I start to feel the need to have a bm I:
click to choose one need to go right away can wait a little while to go can comfortably hold it for a while can hold it until much later
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: Choose one never less than once a year every few months/ a few times a year monthly weekly every few days all the time

I get softer than normal BMs or diarrhea: Choose one never rarely frequently daily

(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: Choose one never less than once a year every few months/ a few times a year monthly weekly daily

I can't hold it and have a bm on myself: Choose one never less than once a year every few months/ a few times a year monthly weekly daily

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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:)

I cover the seat before sitting
I use a seat cover (if available); I don't punch out the center

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: Click to choose one hold it just go anyway wipe the seat cover the seat, then go go on the floor
when I have to have a bm, I: Click to choose one hold it just go anyway wipe the seat cover the seat, then go go on the floor

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

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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.

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	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: Click to choose one single sheets of toilet paper several folded sheets a wad of paper

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

I wipe while sitting, bending, standing, raising one legsquatting.


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

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:

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	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

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

Breakfast:	Lunch:	Dinner:
I usually eat: Nothing very little a medium sized meal a heavy meal 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: Nothing very little a medium sized meal a heavy meal 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: Nothing very little a medium sized meal a heavy meal 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:

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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

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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

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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

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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)

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(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:
click to choose one never a few times in an emergency occasionally (often) when it is more convenient than going inside (always) when ever I am outdoors and need to go

I have had a BM outdoors:
click to choose one never a few times in an emergency occasionally (often) when it is more convenient than going inside (always) when ever I am outdoors and need to go

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