I’m an ANGRY Quad!

BIG MEDICAL HAS IGNORED OUR PARALYZED BOWELS!

First Name:

Email:

Telephone:

Current bowel program:

Digital stimulation

Laxatives

Mini-Enemas

Digital removal

Magic Bullet

Old-fashioned Enema

Please describe who helps you:

Spouse

Attendant

Outside Nurse

Friends

Bowel accidents:

Yes

Frequently

Never

Sometimes

Diapers:

Yes

No

Hemmorroids:

Yes

Yes-Bleeding

No

Never happened

Private insurance:

Yes

No

Can you operate a Computer:

Yes

No

Frequent UTI:

Yes

Yes... many times annually

No

No... never

Does your bowel program smell badly:

No

Yes... horribly

Yes... very embarrassing

Bowel prevent you from working:

Yes

Yes... no one will help me with my bowel problems

No

Bowel preventing you from finishing school:

Yes

Yes... too many problems happen at school

No

Bowel problems making you homebound:

Yes... I'm afraid to go anywhere

No... I guess I am lucky

Bowel program requires:

1 hour

2 hours

3 hours

4 hours or more

Male Female:

M

F

We respect your email privacy

All of your information will be maintained in privacy! Your name will not be associated with this information for public distribution.

I’m an ANGRY Quad!

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