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Crohn's Disease Checklist
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.
2.
Have you been diagnosed with Crohn's disease?
Yes
No
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
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
5.
Have you ever had surgery for Crohn's disease?
Yes
No
6.
Have you ever had an intra-abdominal abscess (infection), abscess around your anus/rectum, or fistula?
Yes
No
7.
Are you currently taking medication for Crohn's disease?
Yes
No
I don't know.
If yes, please list medications:
8.
Using tobacco products can worsen the symptoms of Crohn’s disease. Do you smoke or use other tobacco products?
Yes
No
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
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
11.
Osteoporosis screening
Many 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
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
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
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
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
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.com
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