The FMS Community I.B.S. Symptom Journal

Fill out the journal daily and present to your health care provider when seeking treatment.

Date: ___/___/___

Pain Bloating Diarrhea Constipation Nausea  
Time Symtoms Began:

____
a.m   p.m.

____
a.m   p.m.
____
a.m   p.m.
____
a.m   p.m.
____
a.m   p.m.
Time Symptoms Ended: ____
a.m   p.m.
____
a.m   p.m.
____
a.m   p.m.
____
a.m   p.m.
____
a.m   p.m.
Rate the severity of each symptom:
1/mild 10 severe

1  2  3  4 5
6  7  8  9  10

1  2  3  4  5
6  7  8  9  10
1  2  3  4  5
6  7  8  9  10
1  2  3  4  5
6  7  8  9 10
1  2  3  4  5
6  7  8  9  10
What was I doing when symptoms began?
Food Eaten prior to symptoms.
Amount of Food Eaten:
1) Less than normal
2) Normal
3) A bit more than normal
4) Excessive amount.

1   2  3  4

1  2  3   4 1  2  3   4 1  2  3   4 1  2  3   4
Medication tried.
Notes:
List trigger foods, adverse medication reactions etc.

Do not try to treat your IBS on your own, over use of laxatives, anti-diarrheals and supplements can cause new health problems.
Contact a health care provider for professional advice.
Please feel free to print off as many copies as you need.

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