Crohn's Disease Checklist Question Title * 1. Crohn's disease is a chronic inflammatory disease of the intestines that causes abdominal pain, vomiting, diarrhea, among other symptoms. It is often diagnosed by a gastroenterologist with a colonoscopy and biopsies, but sometimes requires other testing. If you have been given a diagnosis of Crohn's Disease then THIS CHECKLIST IS TO HELP YOU!We designed this checklist to help you make sure you are getting all the care you need to control your disease and remain as healthy as possible!IF YOU DON'T HAVE ANSWERS TO THESE, THAT'S OKAY! Use the information to help you ask questions at your next doctor's appointment or make a new appointment to discuss them further. Question Title * 2. Have you been diagnosed with Crohn's disease? Yes No Question Title * 3. People can be diagnosed with Crohn's Disease at any age, but those who are diagnosed early in life have a more serious risk of complications. How old were you when diagnosed with Crohn's disease? Less than 18 years of age 18 to 30 Over 30 years of age Question Title * 4. Do you know what area of your body is affected by Crohn's disease? If so, indicate below. Small intestine Large intestine or colon Perianal region or anorectal region I don't know Question Title * 5. Have you ever had surgery for Crohn's disease? Yes No Question Title * 6. Have you ever had an intra-abdominal abscess (infection), abscess around your anus/rectum, or fistula? Yes No Question Title * 7. Are you currently taking medication for Crohn's disease? Yes No I don't know. If yes, please list medications: Question Title * 8. Using tobacco products can worsen the symptoms of Crohn’s disease. Do you smoke or use other tobacco products? Yes No Question Title * 9. Symptoms of Crohn’s disease can be classified as mild, moderate, or severe depending on how many symptoms you have. Do you have any of the following signs or symptoms of active Crohn’s disease?If you are having 2 or more of the following symptoms, you might need to discuss it with your gastroenterologist sooner. Fever Abdominal pain Blood in stool Weight loss Diarrhea Diarrhea that wakes you up at nighttime Joint pain New skin rashes or sores in the mouth Question Title * 10. Have you had the routine laboratory testing you need?People with Crohn’s disease should have regular laboratory blood testing. Below are some lab tests which are commonly ordered for patients with Crohn’s. Complete blood count (CBC) Liver tests Iron studies C-reactive protein Stool studies Question Title * 11. Osteoporosis screeningMany Crohn's disease patients are at increased risk for bone loss (osteoporosis). If you have Crohn's disease and ANY of the following criteria, you should ask your doctor about screening for Crohn's disease. Older than 60 Post-menopausal women Have had 3 months of steroid use in your lifetime (e.g. prednisone) Currently taking prednisone or other corticosteroid Had bone fractures in the past Question Title * 12. Have you had all your vaccinations?Patients with Crohn's disease are at increased risk of infection, and several of the medications used for Crohn's disease can increase this risk. It is important that you discuss vaccinations with your doctor.Have you had the following vaccinations? Tetanus, diptheria, pertussis, measles/mumps/rubella Influenza vaccine (flu shot) Shingles vaccine for people over 60 Hepatitis A Hepatitis B I don't know Question Title * 13. Have you been screened for other cancers?Patients with Crohn's disease or who are on medication for Crohn's disease may need screening for other cancers.Have you been screened for the following cancers? Skin cancer Cervical cancer (pap smear) I have not been screened for any other cancers Question Title * 14. Are you taking your medications?It is very important that patients with Crohn's disease take all of their prescription medications as prescribed.Which of these statements applies to you? I never miss my medication for Crohn's disease I miss at least three doses of medication per week I miss at least one dose of medication per day I miss multiple doses of medication per day I am not taking my medication for Crohn's disease Question Title * 15. Are you getting the nutrition you need?Patients who require medication for Crohn's disease have special nutritional requirements.Please check off which statements apply to you. I eat a healthy and balanced diet My weight is stable I am on calcium/vitamin D supplements I take a multivitamin Question Title * 16. This checklist is designed to help you keep track of your care and to help you ask questions at your doctor appointments. You can find additional information at the Wichita Falls Gastroenterology Associates website: http://www.wfgastro.comPlease tell us how helpful this checklist was to you. Extremely helpful Somewhat helpful Not helpful at all Done