1
IBD Registry, CD Initial Visit
[
Date: _ _ / _ _ / _ _
patient sticker ]
Registration Information
Date of Birth: _ _ / _ _ / _ _
Gender:
o Male
o Female
Telephone #: (_ _ _) - _ _ _ - _ _ _ _
Attending MD: ________________
Year of IBD diagnosis: _ _ _ _
Demographic and Family History Information
Hispanic:
Race:
o Yes
o No
o White
o Black/African American
o Asian
o American Indian/Alaskan Native
o Native Hawaiian/Pacific Islander
o More than one race
o Other (specify: _________________)
o Unknown
IBD Affected
Father:
Mother:
CD
___
___
UC
___
___
Type Unclear
___
___
Unaffec ted
___
___
Unknown
___
___
No. Siblings
No. Children
___
___
___
___
___
___
___
___
___
___
Smoking History Prior to Diagnosis
Smoking at diagnosis or onset of symptoms (smoking is defined as >6 cigarettes/day for >5 months):
o Yes o Ex-Smoker o No o Unknown
If yes or ex-smoker:
Year started: _ _ _ _
Year stopped: _ _ _ _
2
Macroscopic Disease Location (check all that apply):
Upper GI:
Jejunal:
Ileal:
o Yes
o Yes
o Yes
o No
o No
o No
o Unknown
o Unknown
o Unknown
Colon:
Perianal:
o Yes
o Yes
o No
o No
o Yes
o Unknown
o Unknown
o Unknown
Surgery
Surgery for complication or treatment of CD:
If yes:
Year
____
o No
Type of procedure
o Resection and primary anast. o Resection, primary anast., and protective stoma
o Resection and stoma
o Stoma
Resection of:
o Stomach
o NeoTI
o Transverse
If stoma:
Type:
Other procedures:
o Duodenum o Jejunum
o Appendix
o Cecum
o Descending o Sigmoid
o Ileostomy
o
o
o
o
o
o Ileum
o Ascending
o Rectum
o Colostomy
Stricturoplasty
I&D perianal
Seton placement
Advancement flap
IPAA
o
o
o
o
Abd abscess drainage
Perianal fistulotomy
Stoma revision
Other
Year
____
Type of procedure
o Resection and primary anast. o Resection, primary anast., and protective stoma
o Resection and stoma
o Stoma
Resection of:
o Stomach
o NeoTI
o Transverse
If stoma:
Type:
Other procedures:
o Duodenum o Jejunum
o Appendix
o Cecum
o Descending o Sigmoid
o Ileostomy
o
o
o
o
o
o Ileum
o Ascending
o Rectum
o Colostomy
Stricturoplasty
I&D perianal
Seton placement
Advancement flap
IPAA
o
o
o
o
If more surgeries, please attach additional sheets.
Abd abscess drainage
Perianal fistulotomy
Stoma revision
Other
3
Extraintestinal Manifestations & Complications:
If yes:
Joint symptoms related to disease activity:
Ankylosing spondylitis/sacro-ileitis:
Erythema nodosum:
Pyoderma:
Oral aphthous ulcers:
Ocular inflammation:
Osteoporosis/osteopenia:
Liver disease:
PSC:
Other:
Pouchitis:
o Yes
o No
o Unknown
o Yes
o Yes
o Yes
o Yes
o Yes
o Yes
o Yes
o No
o No
o No
o No
o No
o No
o No
o Unknown
o Unknown
o Unknown
o Unknown
o Unknown
o Unknown
o Unknown
o Yes
o Yes
o Yes
o No
o No
o No
o Unknown
o Unknown
o Unknown
Cancer and Dysplasia
Year of Dx
Non-GI
Cancer:
Dysplasia:
Lymphoproliferative disorder:
o Yes
o Yes
o Yes
o No
o No
o No
o Unknown
o Unknown
o Unknown
____
____
____
GI excluding CRC
Cancer:
Lymphoproliferative disorder:
o Yes
o Yes
o No
o No
o Unknown
o Unknown
____
____
CRC or Dysplasia of colon:
Dysplasia:
CRC:
o Yes
o Yes
o No
o No
o Unknown
o Unknown
____
____
Gender Specific Issues:
Ever pregnant:
o Yes o No o Unknown
o Not applicable
Infertility (the inability to naturally conceive a child or the inability to carry a pregnancy to term):
o Yes o No o Unknown
o Not applicable
IBD Studies:
Currently enrolled in therapeutic IBD study:
o Yes o No o Unknown
List trial: ______________________________________
Previously enrolled in therapeutic IBD study:
o Yes o No o Unknown
List trial: ______________________________________
4
Current Medications:
Corticosteroids (topical or oral):
Aminosalicylates (topical or oral):
6MP/Azathioprine:
Methotrexate:
Calcineurin inhibitor:
Antibiotics:
Anti-TNF:
Alpha-4-integrin inhibitor:
o Yes
o Yes
o Yes
o Yes
o Yes
o Yes
o Yes
o Yes
o No
o No
o No
o No
o No
o No
o No
o No
o Unknown
o Unknown
o Unknown
o Unknown
o Unknown
o Unknown
o Unknown
o Unknown
o Yes
o No
o Unknown
IBD Serologies:
IBD serologies performed: