Bowel Record Chart This chart is designed to give your health care professional a good idea of your child's bowel habits. Please fill in the chart every day if you can (referring to the Bristol Stool Form Scale) for as long as you have been asked to do so. This will also help you monitor your child's progress. Child's Name: Date Chart Started: Medication: Pain and Where Type of Quantity distress Pants soiled? Dose of laxatives taken was the Stool of stool when stool passing passed Type of soiling Date Time stool Number of (use number Stained times ▪Medium ▪Yes ▪Toilet ▪ from Bristol Breakfast Lunch Dinner Night Stool Form during the ▪Small ▪Some Scale) day ▪None ▪No ▪Other ▪Solid
Bowel Record Chart This chart is designed to give your health care professional a good idea of your child's bowel habits. Please fill in the chart every day if you can (referring to the Bristol Stool Form Scale) for as long as you have been asked to do so. This will also help you monitor your child's progress. Child's Name: Date Chart Started: Medication: Date Time Type of Stool Quantity of stool Pain and distress when passing stool Where was the stool passed Pants soiled? Dose of laxatives taken (use number from Bristol Stool Form Scale) Number of times during the day Type of soiling Breakfast Lunch Dinner Night ▪Medium ▪Yes ▪Toilet ▪ Stained ▪Small ▪Some ▪None ▪No ▪Other ▪Solid
Bowel_Record_Chart.docx