Rome III Diagnostic Questionnaires


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usage of these items and products are now available. Please contact Michele Pickard at mpickard@theromefoundation.org



The Rome Foundation has developed diagnostic questionnaires in coordination with the Rome III committees to assist physicians, health care professionals and researchers in identifying individuals who have one or more functional gastrointestinal disorders (FGIDs). An introduction (preamble, instructions for respondents, information for clinicians/investigators, and scoring algorithms are included at the beginning of each file. Separate questionnaire files are available to meet various needs, including:

These are all PDFs for download

For Adults

  1. A self-report integrated questionnaire to diagnose adults for one or more FGIDs, including alarm symptoms/red flags.Download Here
  2. Eight modules based on the Rome III criteria that can be used to screen for the following specific single diagnoses or groups:

    1. Irritable Bowel Syndrome (IBS) Module
    2. Constipation Module
    3. Functional Dyspepsia Module
    4. Nausea, Vomiting and Belching Disorders Module
    5. Functional Esophageal Disorders Module
    6. Functional Abdominal Pain Syndrome (FAPS) Module
    7. Functional Biliary Disorders Modulerevised
    8. All Functional Bowel Disorders (IBS-Constipation, IBS-Diarrhea, IBS-Mixed, IBS-Unspecified)
  3. A Psychosocial Alarm Questionnaire, containing screening questions within a clinical context (and are not designed for survey purposes) to help identify psychosocial problems commonly faced by patients with FGIDs. Download here

For Children & Adolescents

Download here
  1. Self-report form for children and adolescents (10 years of age and older)
  2. Parent-report form for children (4 years of age and older)

For questions regarding these questionnaires or scoring algorithms, please contact:

Rome Foundation, Inc.
P.O. Box 6524
Raleigh, NC 27628
Phone: 919-539-3051
Fax: 919-900-7646
mpickard@theromefoundation.org