Spina Bifida Association of Western New York

Bowel Continence Questionnaire

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Bowel Continence Satisfaction Questionnaire
Age of client
Level of feeling/movement
Level of lesion
Who is filling out the survey?
1. Do you have a bowel program at present?
2. If no, are you satisfied with your level of continence?
3. If yes, what is your bowel program now?	If other, please eplain
4. Do you/your child have bowel accidents?
5. How many bowel accidents do you have?
6. How many bowel accidents are acceptable to you?
7. Have you ever been embarrassed because of a bowel accident?
8. Do you ever worry about having a bowel accident at school or work?
9. Have you every stayed home instead of going to school, work or with friends because you were afraid of a bowel accident?
10. How satisfied are you with your bowel program?
11. How much time a week do you spend doing it?
12. How many days a week do you do the bowel program?
13. What have you tried in the past?
14. Where do you get your information regarding bowel continence? Check all that apply	From other parents/individuals with spina bifida From the Internet From clinic staff From other health care providers Other
15. What would you find helpful in assisting you/your child achieve bowel continence? Check all that apply	Nothing at this time-not interested More direction at clinic From clinic staff From other health care providers Other
16. What comments do you have that we have not touched upon?