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MAOGIT - DQLQ, GerdQ, GSRS, BSVAS

Digestion Associated Quality of Life Questionnaire Upper Gastrointestinal Symptoms Questionnaire The Gastrointestinal Symptoms Rating Scale Bloating Symptoms Visual Analogue Scale

"*" indicates required fields

Your participant ID is your first and last initials, followed by the day and month of your birth. For example, John Smith born January 24th would be : JS2401
What timepoint are you completing this questionnaire?*
Please check your emails for your screening number or contact your Trial Coordinator
You should be able to find this number on your study product.

DQLQ (Digestion - associated Quality of Life Questionnaire)

The following questions are designed to measure the effect of digestive symptoms on your daily life over the past 7 days. For each question, please click one response.

Digestive symptoms include, but are not limited to: stomach ache or pain, acid reflux, nausea, bloating, heartburn, hunger pains, rumbling in the stomach or belly, burping, passing gas, diarrhea, hard stools, constipation, loose stools or the urgent need to have a bowel movement.

For each statement, please answer how often you experienced these events in your daily life for the past 7 days.
Please refer to the scale below for the percentage of time during the past week.

Never (0%)Rarely (10%)Occasionally (30%)Sometimes (50%)Frequently (70%)Usually (90%)Always (100%)
Physical activities (running, walking, gardening, golfing etc) were unpleasant or avoided.
My usual appetite changed.
I was inconvenienced or physically uncomfortable.
I avoided certain foods.
I was self-conscious or bothered in public or around others.
I used the restroom less than I wanted.
I was distracted while doing various activities.
social activities (spending time with friends or family, going out to eat, etc) were unpleasant or avoided.
consuming foods and beverages was less enjoyable.

GerdQ

Questionnaire for patients with upper gastrointestinal symptoms
Never1 day2 to 3 daysBetween 4 and 7 days
1. In the last week, how many days have you had a burning sensation or burning pain in your chest?
2. In the last week, how many days have you noticed that the contents of your stomach have come up into your throat or mouth?
3. In the last week, how many days have you felt pain in the pit of your stomach?
4. In the last week, how many days have you been nauseated or felt like throwing up?
5. In the last week, how many nights have you had trouble sleeping well because your stomach content has come into your throat or mouth?
6. In the last week, how many days have you taken medication other than what your doctor prescribed (such as Almax, fruit salts, or Rennie chewable tablets) for burning pain or because your stomach content has come into your throat or mouth?

Bloating Symptoms VAS

For each question below, select a point on the scale that corresponds with the severity experienced over the past week.
0 = No Symptom
10 = Most Severe
0 = No Symptom
10 = Most Severe
0 = No Symptom
10 = Most Severe

THE GASTROINTENSTINAL SYMPTOM RATING SCALE (GSRS)

Please read this first:

This survey contains questions about how you have been feeling and what it has been like DURING THE PAST WEEK. Select the choice that best applies to you and your situation.

1. Have you been bothered by PAIN OR DISCOMFORT IN YOUR UPPER ABDOMEN OR THE PIT OF YOUR STOMACH during the past week?*
2. Have you been bothered by HEARTBURN during the past week? (By heart burn we mean an unpleasant stinging or burning sensation in the chest.)*
3. Have you been bothered by ACID REFLUX during the past week? (By acid reflux we mean the sensation of regurgitating small quantities of acid or flow of sour or bitter fluid from the stomach up to the throat.)*
4. Have you been bothered by HUNGER PAINS in the stomach during the past week? (This hollow feeling in the stomach is associated with the need to eat between meals.)*
5. Have you been bothered by NAUSEA during the past week? (By nausea we mean a feeling of wanting to throw up or vomit.)*
6. Have you been bothered by RUMBLING in your stomach during the past week? (Rumbling refers to vibrations or noise in the stomach.)*
7. Has your stomach felt BLOATED during the past week? (Feeling Bloated refers to swelling often associated with a sensation of gas or air in the stomach.)*
8. Have you been bothered by BURPING during the past week? (Burping refers to bringing up air or gas from the stomach via the mouth, often associated with easing a bloated feeling.)*
9. Have you been bothered by PASSING GAS OR FLATUS during the past week? (Passing gas or flatus refers to the need to release air or gas from the bowel, often associated with easing a bloated feeling.)*
10. Have you been bothered by CONSTIPATION DURING THE PAST WEEK? (CONSTIPATION REFERS TO A REDUCED ABILITY TO EMPTY THE BOWELS.)*
11. Have you been bothered by DIARRHEA during the past week? (Diarrhea refers to a too frequent emptying of the bowels.)*
12. Have you been bothered by LOOSE STOOLS during the past week? {If your stools (motion) have been alternately hard and loose, this question only refers to the extent you have been bothered by the stools being loose.}*
13. Have you been bothered by HARD STOOLS during the past week? {If your stools (motion) have been alternately hard and loose, this question only refers to the extent you have been bothered by the stools being hard.}*
14. Have you been bothered by an URGENT NEED TO HAVE A BOWEL MOVEMENT during the past week? (This urgent need to go to the toilet is often associated with a feeling that you are not in full control.)*
15. When going to the toilet during the past week, have you had the SENSATION OF NOT COMPLETELY EMPTYING THE BOWELS? This feeling of incomplete emptying means that you still feel a need to pass more stool despite having exerted yourself to do so.)*

PLEASE CHECK THAT ALL QUESTIONS HAVE BEEN ANSWERED!

THANK YOU FOR YOUR CO-OPERATION.

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