What do you mean by constipation?
Duration of symptoms:__
What about your symptoms worries you the most?
Goal: What do you hope to gain or achieve?
Bristol stool chart, type:_____
Rome III Criteria
Is the symptom onset  ≥ 6 months?__
In the last 3 months, have you had any of the following:
-Fewer than 3 bowel movements per week? __
-Hard or lumpy stools more than 25% of the time?__
-Straining with defecation more than 25% of the time?__
-Sensation of incomplete evacuation more than 25% of the time?__
-Manual maneuvers necessary to facilitate defecation more than 25% of the time?__
-Sensation of anorectal obstruction more than 25% of the time?__
Symptoms of IBS? ___
Rarely (almost never) has loose stools without the use of laxatives?

Other symptoms?
R/o alarm features. Patient denies any blood on toilet paper, stools, or toilet bowl. No dark tarry stools. No family history of colorectal cancer.
Medication review: No Drugs that cause constipation.
DDx: Will identify and treat reversible causes

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