How Well Is Your Crohn's Disease Being Managed?

1. Over the past 2 weeks, have you experienced an increase in the frequency of your bowel movements?

• Yes, the frequency of my bowel movements has increased substantially
• Yes, the frequency has increased moderately
• Yes, the frequency has increased slightly
• No, the frequency has remained the same

2. Over the past 2 weeks, how often have your bowel movements been loose?

• All of the time
• Most of the time
• Some of the time
• Hardly any of the time
• None of the time

3. In the past 2 weeks, have you had more abdominal pain or cramping?

• Yes, my pain and cramping are significantly more frequent, or present constantly
• Yes, they're somewhat more frequent
• Yes, they're slightly more frequent
• I've had no pain or cramping or I've experienced no change in their frequency

4. In the past 2 weeks, how often have you been unable to go to work, attend school, or keep social engagements because of bowel problems related to Crohn's disease?

• All of the time
• Most of the time
• Some of the time
• Hardly any of the time
• None of the time

5. Relatively speaking, how have your energy levels been over the past 2 weeks?

• Much lower than normal and/or have no energy at all
• Somewhat lower than normal
• A little lower than normal
• Higher than normal or no change

6. How much difficulty have you had performing leisure or sports activities over the past 2 weeks?

• Extreme difficulty and/or impossible
• A lot of difficulty
• Some difficulty
• Minimal difficulty
• No difficulty

7. Have you experienced noticeable weight loss over the past 1-6 months, particularly if you have not been trying to lose weight? For example, if you weigh 150 pounds and you've lost 15 pounds, that's 10 percent weight loss - a significant amount in a short period.

• Yes, I've lost more than 5 percent of my weight in 1 month or more than 10 percent in 6 months
• Yes, I've lost less than or equal to 5 percent in 1 month or less than or equal to 10 percent in 6 months
• No, my body weight has remained stable

8. Over the past 2 weeks, has the frequency of your rectal bleeding increased?

• Yes, I've had significantly more frequent or constant rectal bleeding
• Yes, it's somewhat more frequent
• Yes, it's slightly more frequent
• No change in frequency and/or rectal bleeding is absent

9. How frequently do you have worries or anxieties related to your Crohn's disease? These may include concerns about cancer, worries that symptoms will never improve, or anxiety about having a relapse.

• All of the time
• Most of the time
• Some of the time
• Hardly any of the time
• None of the time

10. Over the past 2 weeks, how frequently have you felt an urge to go to the bathroom even though your bowels are empty?

• All of the time
• Most of the time
• Some of the time
• Hardly any of the time
• None of the time

11. Do you have any extraintestinal (outside of the intestines) symptoms ? Common extraintestinal symptoms related to Crohn's  include eye inflammation, arthritis, osteoporosis, skin rashes, inflammation of the liver or bile ducts, kidney stones, and gallstones. 

• Yes
• No