Constipation 2

How long have you had constipation?
MM
DD
YYYY
What is your date of birth?
MM
DD
YYYY
How many bowel movements on average do you have per week?
How many bowel movements on average do you have per day?
Have you had a colonoscopy in the last 5 years?
From a scale from 1-10 (10 being the worst pain) how much pain do you currently have?
Are your stools soft or hard?
- Soft
- Hard
Do you currently have medical insurance?
- Yes,
- No
Do you have any other acute or chronic illness, such cardiovascular, endocrine, immune system, etc..) If so what is the illness?
Are you diagnosed with lactose intolerance or celiac disease?
What is your address?
Street Address City ZIP Code
When is the best time to reach you?