Rome IV Questionnaires

Name of InstrumentDescription of InstrumentAdditional LanguagesKey Citations
Rome IV Book
Rome IV
Two volume textbook of all Rome IV content that contains appendices with all Rome IV questionnaires. Appendices: A) Rome IV Diagnostic Criteria, B) Comparison Table of Rome III and Rome IV Adult and Pediatric criteria,C) Rome IV Diagnostic Questionnaire for Adult FGIDs, D) Rome IV Psychosocial Alarm Questionnaire for FGIDs, E) Psychosocial Assessment of FGIDs flowchart, F) Rome IV Diagnostic Questionnaire for Pediatric FGIDs (Children and adolescent and Neonate and toddler questionnaires)ChineseDrossman DA (ed.) et al. Rome IV Functional GI Disorders – Disorders of Gut-Brain Interaction. pp 1-1741 Raleigh NC, Rome Foundation 2016
Rome IV Diagnostic Questionnaire for Adult FGIDs
R4DQ
The Rome IV Diagnostic Questionnaire for Functional Gastrointestinal Disorders in Adults (R4DQ) translates the Rome IV diagnostic criteria into questions that can be understood and reported by patients and research subjects. The intended uses of the R4DQ are (1) to provide inclusion criteria for clinical research studies, (2) to serve as case definitions for epidemiological surveys, and (3) to assist clinicians in arriving at a provisional diagnosis. Diagnostic questionnaires were also developed for pediatric FGIDs.Arabic-Egypt, Arabic-Israel, Arabic-Israel-Bedouins, Arabic-Saudi Arabia, Bahasi-Malay, Bahasi-Indonesia, Bahasi-Singapore, Bengali-India, Bengali-Bangladesh, Chinese, Chinese-Singapore, Dutch, Dutch-Belgium, English-USA, English-Australia, English-Canada, English-Ghana, English-Singapore, English-UK, Farsi, French-France, French-Belgium, French-Canada, German, Hebrew, Hindi, Italian, Japanese, Korean, Polish, Portuguese-Brazil, Romanian, Russian-Russia, Russian-Israel, Spanish-Mexico, Spanish-Argentina, Spanish-Colombia, Spanish-Spain, Swedish, Telugu, Turkish
Rome IV Book Appendix C, Available by license from Rome Foundation.
Rome IV Psychosocial Guidelines and Flags for Referring to a Mental Health Provider
R4 Psychosocial Alarm Red Flags
Provides a checklist of 9 key questions (“red flags”) that would alert the clinician to seek mental health consultation for. Question items relate to anxiety, depression, suicidality, sexual or physical abuse, severe pain, somatic symptom anxiety, impairment and drug or alcohol abuseChineseRome IV Book Appendix D
Rome IV Diagnostic Questionnaire on Pediatric Functional Gastrointestinal Disorders– Child
R4PDQ
Child: Self-report form for Children and Adolescents (10 years and older)English, Spanish, Danish, ChineseRome IV Book Appendix F
Available by license from Rome Foundation.
Rome IV Diagnostic Questionnaire on Pediatric Functional Gastrointestinal Disorders– Child
R4PDQ-child
Parent-report form for Children (4 years and older)English, Spanish, Danish, ChineseRome IV Book Appendix F
Available by license from Rome Foundation.

Rome IV Diagnostic Questionnaire for Pediatric Functional Gastrointestinal Disorders-Toddler
R4PDQ-toddler
Parent-report form for Neonates and Toddlers (0-3 years)English, Spanish, Danish, ChineseRome IV Book Appendix F
Available by license from Rome Foundation.
Rome III Book
Rome III
Spanish, Chinese and JapaneseDrossman DA (ed.) et al. Rome III The Functional GI Disorders. pp 1-1047. McLean VA. Degnon Associates. 2006
Questionnaires for Adults and ChildrenAdult and Pediatric Rome III Questionnaires are available on request. Contact Mark Schmitter at mschmitter@theromefoundation.orgSpanish, Chinese, Japanese, PortugueseRome III Book, Appendices C, E

Questionnaires for Research and Clinical Practice

All Questionnaires listed below are available by license from Rome Foundation.
Name of InstrumentDescription of InstrumentAdditional LanguagesKey Citations
Bristol Stool Form Scale
BSFS
To assess intestinal transit rate by classifying feces into seven groupsArabic-Egypt, Arabic-Israel, Arabic-Israel-Bedouins, Arabic-Saudi Arabia, Bahasi-Malay, Bahasi-Indonesia, Bahasi-Singapore, Bengali-India, Bengali-Bangladesh, Chinese, Chinese-Singapore, Dutch, Dutch-Belgium, English-USA, English-Australia, English-Canada, English-Ghana, English-Singapore, English-UK, Farsi, French-France, French-Belgium, French-Canada, German, Hebrew, Hindi, Italian, Japanese, Korean, Polish, Portuguese-Brazil, Romanian, Russian-Russia, Russian-Israel, Spanish-Mexico, Spanish-Argentina, Spanish-Colombia, Spanish-Spain, Swedish, Telugu, Turkish
Lewis SJ,Heaton KW. Stool form scale as a useful guide to intestinal transit time. Scand J Gastroenterol 1997;32:920-924
Celiac Disease- Quality of Life Survey
CD-QOL
The final CD-QOL has 20 items across four clinically relevant subscales (Limitations, Dysphoria, Health Concerns, and Inadequate Treatment). The CD-QOL has high internal consistency, reliability, and psychometric validation indicates both convergent and discriminate validity. The CD-QOL is a reliable and valid measure of coeliac disease related QOL. As a new disease-specific instrument, it is likely to be a useful tool for evaluating patients with this disorder.Dutch, Japanese, Portuguese, Czech, Italian, SpanishDorn,S.D.; Hernandez,L.; Minaya,M.T.; Morris,C.B.; Hu,Y.; Leserman,J.; Lewis,S.; Lee,A.; Bangdiwala,S.I.; Green,P.H.R.; Drossman,D.A. The Development and validation of the coeliac disease quality of life survey (CD-QOL). Alimentary Pharm Therapeutics 2009;31:666-675

Casellas F et al. Transcultural adaptation and validation of the celiac disease quality of life (CD-QOL) survey, a specific questionnaire to measure quality of life in patients with celiac disease. Rev Exp Enferm Dig (Madrid). 2013;105:585-593

Functional Bowel Disorders Severity Index
FBDSI
This instrument quantifies the illness severity of patients with painful functional bowel disorders (IBS, CAPS, painful constipation). It was validated using 4 sites in the US, Canada and the UK where pain severity measures were validated to physician rating of severity. The measure relies heavily on pain severity and health care utilization as scale options. Therefore the instrument is useful for one time assessment for research but is not responsive to change.Hebrew Drossman DA et al. Functional bowel disorders: A multicenter comparison of health status and development of an illness severity disorder index. Dig Dis Sci 1995;40:986-995.

Sperber AD et al. Use of the Functional Bowel Disorder Severity Index (FBDSI) in a study of patients with IBS and fibromyalgia. Am J Gastroenterol 2000; 95:995-998
Irritable Bowel Syndrome- Quality of Life survey
IBS-QOL
The IBS-QOL is currently the most validated and highly responsive self-report quality-of-life measure specific to Irritable Bowel Syndrome (IBS) that can be used to assess the impact of IBS and its treatment. The IBS-QOL was developed using a needs based model. There are 3 validation studies done in English and several other international publications. Afrikaans, Arabic, Bengali, Bulgarian, Cantonese, Czech, Danish, English, Finnish, French, German, Gujarati, Hebrew, Hindi, Hungarian, Italian, Kannada, Korean, Latvian, Malay, Malayalam, Mandarin Chinese, Marathi, Norwegian, Panjabi, Polish, Portuguese, Romanian, Russian, Slovak, Spanish, Swedish, Tamil, Thai, Telugu, Ukrainian, UrduPatrick DL, Drossman DA, Frederick IO, DiCesare J, Puder KL. Quality of life in persons with irritable bowel syndrome: Development of a new measure. Dig Dis Sci 1998;43:400-411.

Drossman DA, Patrick DL, Whitehead WE, Toner BB, Diamant NE, Hu YJB, Jia H, Bangdiwala SI. Further validation of the IBS-QOL: A disease specific quality of life questionnaire. Am J Gastoenterology 2000;95:999-1007.

Drossman D, Morris CB, Hu Y, Toner BB, Diamant N, Whitehead WE, Dalton CB, Leserman J, Patrick DL, Bangdiwala SI. Characterization of health related quality of life (HRQOL) for patients with functional bowel disorder (FBD) and its response to treatment. Am J Gastroenterol 2007;102:1442-1453.
Irritable Bowel Syndrome- Symptom Severity Scale
IBS-SSS
This is the most frequently used severity measure for evaluating IBS severity. Items relate to pain, bowel dysfunction and overall well being. It is commonly used as an outcome measure in clinical trials because it is highly responsive to change with treatment. Scores are based on a visual analog scale but the Rome Foundation has an alternate version where a numerical score is used.Bulgarian, Czech, Hungarian, Latvian, Slovak, Arabic-Egypt, Arabic-Israel, Arabic-Israel-Bedouins, Arabic-Saudi Arabia, Bahasi-Malay, Bahasi-Indonesia, Bahasi-Singapore, Bengali-India, Bengali-Bangladesh, Chinese, Chinese-Singapore, Dutch, Dutch-Belgium, English-USA, English-Australia, English-Canada, English-Ghana, English-Singapore, English-UK, Farsi, French-France, French-Belgium, French-Canada, German, Hebrew,Hindi, Italian, Japanese, Korean, Polish, Portuguese-Brazil, Romanian, Russian-Russia, Russian-Israel, Spanish-Mexico, Spanish-Argentina, Spanish-Colombia, Spanish-Spain, Swedish, Telugu TurkishFrancis CY, Morris J, Whorwell PJ, The irritable bowel severity scoring system. A simple method of moitoring IBS symptoms and its progress. Alimentary Pharm Therap 1997;11:395-402
Rating form of Inflammatory Bowel Disease Patient Concerns
RFIPC
This is a frequently used 25 item health status assessment of perceived health status for IBD (UC and Crohn’s disease). It evaluates the worries and concerns associated with IBD and its treatments. The questionnaire has a single item summary score as well as several health status indices (impact of disease, complications of disease, body stigma, and sexual intimacy). The instrument has concurrent validation as it is highly correlated with several measures of poor daily function.Afrikaans, Arabic, Bosnian, Bulgarian, Croatian, Czech, Estonian, French Canadian, German, Greek, Hebrew, Italian, Japanese, Portuguese, Romanian, Russian, Serbian, Slovak, Spanish, Swedish, Ukrainian, TurkishDrossman DA, Leserman J, LiZ, Mitchell CM, Zagami EA, Partrick DL. The rating form of IBD patient concerns: A new measure of health status. Psychosom Med 1991;53:701-712
Comorbid Medical Conditions Questionnaire
CMCQ
This is an empirically derived questionnaire to measure non-gastrointestinal symptoms that co-exist with Irritable Bowel Syndrome (IBS). Factor analysis of IBS patient symptoms were used to develop the scale and the instrument is rated with 4 subscales: one for psychiatric disorders and 3 for different types of somatic disorders. Concurrent validity was shown with strong correlations with the Cornell Medical Index and the Brief Symptom Inventory – 18.JapaneseMaClean EW, Palsson OS, Turner MJ, Whitehead WE. Development and validation of new disease-specific measures of somatization and comorbidity in IBS. J Psychosom Research. 2012;73:351-355
Satisfaction with Care Scale
SAT-37
This instrument assesses patient satisfaction with care. Although it was developed and validated with patients having irritable bowel syndrome (IBS), the items are generic to perceived care and thus can be used for other GI conditions. The IBS-SAT has 37 items across five clinically relevant subscales (connection with provider, Education, Benefits of visit, Office attributes and access to care). It has extremely high internal consistency and reliability and shows convergent validity with global satisfaction with care as well as with the Physician Satisfaction Questionnaire. Discriminant (known groups) validity was also established.English, Dutch, Japanese, PortugueseDorn SD,,Morris CB, Schneck SE, Hopper TM, Hu YB, Kulkani-Kelapore RR, Weinland SR, Norton WF, Norton WJ, Drossman DA. Development and validation of the irritable bowel syndrome satisfaction with care scale. Clin Gastroetnerol and Hepatol 2011;9:1065-1071
Trauma Questionnaire
Trauma
This is one of the first validated (by interview and self-report) questionnaires to assess physical and sexual abuse. The answers are scaled for adults and children based on presumed severity of physical and/or sexual abuse related to threat, contact (touching) or penetration (vaginal or rectal).English, Dutch, Japanese, PortugueseLeserman J, Li Z, Drossman DA, Toomey TC, Nachman G, Glogau L. Impact of sexual and physical abuse dimensions on health status: development of an abuse severity measure. Psychosom Medicine 1997;59:152-160
Ulcerative Colitis and Crohn's Disease Health Status Scales
UC-CD
This self report health status scale can be used for patients with ulcerative colitis or crohn’s disease. It was developed from a large database of 991 patients belonging to the Crohn’s and Colitis Foundation. The items were derived from factor analysis of symptoms and health status measures. Validation of the items were achieved through strong correlations with general well being, health status and pain as independent measures. By design, this questionnaire was a better predictor of health status than the CDAI.EnglishDrossman DA, Li Z, Leserman J, Patrick DL. Ulcerative colitis and Crohn’s disease health status scales for research and clinical practice. J Clin Gastroenterol 1992;15:104-112
Pictogram for Bloating and Scoring System