Diet Diary

Name*

First Last

Email*

Date*

1. Bowel function - stool characteristics (please give one answer for each of the following)

Stool Color*

dark
very dark
pale
very pale
green

Stool Consistency*

loose
very loose
hard
very hard

Smell*

no smell
light smell
strong smell
very strong smell

Frequency of Stools per day*

once
twice
three times
more
has not pass motion for more than a day
has not pass motion for more than two days
has not pass motion for more than three days
has not pass motion for a week
has not pass motion for more than a week

2. Please list your medication and/or supplementation.

Describe

Please write below your diet diary in a giving week

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

In case you need to upload a file please click below

Max. file size: 512 MB.

Consent*

I explicitly consent to you creating and storing medical records concerning my child's treatment, which may include details concerning medication, treatment and other issues affecting his/hers health conditions, in accordance with the General Data Protection Regulation (GDPR). I understand that these records will be processed in accordance with your 2018 Privacy Notice, a copy of which I have seen published on IBCcare website. I have read and understood the above information and give my explicit consent: