INFLAMMATORY BOWEL DISEASE (IBD)
Patient Status Questionnaire
PATIENT NAME:_____________________________________________ DATE: ________________
Instructions for Completing the Questionnaire:
Please answer these questions considering the past 2 weeks, providing information on your symptoms and their effects on your overall health and life activities. These answers can provide a guide for you and your doctor to record more precisely your progress as time passes. Please feel free to discuss any of these questions and all related subjects with your physician and/or the nursing staff.
1. Please estimate bowel movement frequency per day for the past 2 weeks:
1. bowel movements more frequent than ever
2. extremely frequent
3. some increase in frequency
4. slight increase in frequency
5. normal, no increase in bowel movement frequency
2. Describe your fatigue/tiredness over the past 2 weeks:
1. all the time
2. most of the time
3. sometimes
4. hardly ever
5. never
3. Are you frustrated or anxious?
1. all the time
2. most of the time
3. sometimes
4. hardly ever
5. never
4. How often have you been unable to attend school, work, or perform daily home activities during the past 2 weeks?
1. all the time
2. most of the time
3. sometimes
4. hardly ever
5. never
5. How has your energy been the past 2 weeks?
1. no energy at all
2. a little energy
3. a moderate amount of energy
4. a lot of energy
5. full of energy
6. How frequently have you experienced side effects that you believe are related to your medications (examples: headache, nausea, skin rash or others)?
1. daily
2. most days
3. occasionally
4. very rare
5. never
7. Over the past 2 weeks, how frequently have you experienced painful abdominal cramps?
1. all the time
2. most of the time
3. sometimes
4. hardly ever
5. never
8. How often over the past 2 weeks have you felt generally sick?
1. all the time
2. most of the time
3. sometimes
4. hardly ever
5. never
9. How often during the past 2 weeks have you been worried about not being able to locate a nearby bathroom or toilet?
1. all the time
2. most of the time
3. sometimes
4. hardly ever
5. never
10. How often during the past 2 weeks has your sleep been disturbed?
1. all the time
2. most of the time
3. sometimes
4. hardly ever
5. never
11. How often during the past 2 weeks have you felt depressed?
1. all the time
2. most of the time
3. sometimes
4. hardly ever
5. never
12. How often during the past 2 weeks have you had rectal bleeding with your bowel movements?
1. all the time
2. most of the time
3. sometimes
4. hardly ever
5. never