How long have you had constipation?
What is your date of birth?
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?
Do you currently have medical insurance?
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?
When is the best time to reach you?