Crohn's Life News

1. Number of Liquid or Very Soft Stools
This is the number of times within the past week that you have had bowel movements that were either very soft or liquid.

2. Average Daily Abdominal Pain Rating
This is a rating of your abdominal pain/discomfort levels over the past week.

None Mild Moderate Severe

3. Average Daily General Well-Being
This is a rating of your general well-being levels over the past week.

Well Slightly Below Par Poor Very Poor Terrible

4. Symptoms or findings presumed related to Crohn's disease
(Select all corresponding to patient's symptoms)

 Arthritis or Arthralgia
 Iritis or Uveitis
 Erythema Nodosum, Pyoderma Gangrenosum, Apththous Stomatitis
 Anal Fissure, Fistula or Perirectal Abscess
 Other Bowel-Related Fistula
 Febrile (fever) episode over 100 degrees during past week

5. Taking Lomotil or Opiates for Diarrhea
Answer "Yes" only if you are taking either Lomotil or Opiates for Diarrhea.

 No  Yes

6. Taking Lomotil or Opiates for Diarrhea
Is a Abdominal Mass Present?

None Questionable Present

7. Hematocrit (Optional)
Normal average: For Male = 47, For Female = 42
Skip this section if typical and current are unknown.

Typical (Baseline):      Current:

8. Your Weight (Optional)
Skip this section unless weight changes related to Crohn's are known.

Standard Weight:  lbs.      Current Weight:  lbs.

9. Patient Gender
For comparison to other patients in your gender.

Male Female

10. Patient Age
For comparison to other patients in your age range.

11. Patient Zip Code
For comparison to other patients in your geographic area.

12. Patient Email Address
A copy of the Assessment Results will be emailed for reference.