Patient name:________________________

Inflammatory Bowel Disease Medical Exam Questionnaire
Name_________________________________ DOB___/___/____ Age____ Marital Status________ Race____ Gender M / F Height __________ Present Weight _________ Usual Weight _________ Managed Care ____ ____ Self referral ____ ____ Referring Physician (if different from PCP) Name__________________________ ______________________________ Address_________________________ ______________________________ Phone(____)________ City____________________________ ______________________________ Fax(_____)_________ Phone(______)___________________ (_______)______________________ How would you rate your present health? Excellent_____ Good____ Fair____
What type of Inflammatory Bowel Disease have you been diagnosed with?
d. Collagenous Colitis _____ e. Lymphocytic Colitis_____ f. Other_____ How old were you when you were diagnosed? __________
How old were you when you began having symptoms? __________
Have you ever had an operation for the Inflammatory Bowel Disease? Yes____
If yes, please indicate the type of surgery and the date(s) you had surgery: Stricture Repair (stricturoplasty) __________ Complete colectomy with Ileal pouch anal anastomosis __________ Perianal surgery (fistula repair, seton placement, sphincterectomy, abscess drainage) __________ Have you had any other operations? Yes _____ No_____
If yes, please list the type of surgery, approximate year, hospital, and physician(s) name(s)
1._______________________________________________________________________________ 2._______________________________________________________________________________ 3._______________________________________________________________________________ 4._______________________________________________________________________________ Patient Name:_________________________________ Inflammatory Bowel Disease Medical Exam Questionnaire Please list illness(es) that did not require an operation for which you were hospitalized. (Give dates,
hospital, city and physician in charge.) __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Have you ever had Pouchitis? Yes____
Do you have any fistulas communicating from the GI tract to the skin or some other area of the body?
Are you currently taking medications? Yes ____ No _____
(Include any OTC* drugs, especially vitamins or herbal preparations. If yes, please list with dosages.)
1.__________________________________________
6._______________________________________ 2.__________________________________________ 7._______________________________________ 3.__________________________________________ 8._______________________________________ 4.__________________________________________ 9._______________________________________ 5.__________________________________________ 10.______________________________________ *OTC = Over-The-Counter medications – prescription is not required.
Do you have any allergies to medications? (if yes, list drug and the reaction it caused)
________________________________________________________________________________________ Have you ever been on steroids? Yes _____ No_____ If yes, have you been on:
Oral steroids (prednisone, budesonide, Entocort) __________ Date last taken __________ Steroid enemas or suppositories (Proctofoam, etc.) __________ Date last used __________ Have you ever taken any of these medications? If yes, what dose were you taking and why did you stop taking
it (nausea, other symptoms, wasn’t working, couldn’t afford it, etc.):
Did it help your IBD? (Yes/No) Reason for Stopping Patient Name:_________________________________ Inflammatory Bowel Disease Medical Exam Questionnaire
Have you ever been diagnosed with a blood clot in your leg or your lungs? Yes_____ No____
If yes, when?________________________
When was your last colonoscopy?__________
Have you ever had a Bone Densitometry Test (DEXA scan)? Yes_____ No____
If yes, when?________________________
What was the result? Osteoporosis _____ Osteopenia _____ Normal _____ I don’t know _____ When was the last time that you had an eye examination?________________________________
When was the last time you saw your dentist?__________________________________________
Do you smoke? Yes _____ No _____
If yes, how many packs per day?_______ If no, did you ever smoke? Yes _____ No_____ If yes, when did you quit? ___________
Do you drink alcohol? Yes _____ No_____
If yes, how many drinks do you have in a typical day? ______ Have you ever:
Have you received any of the following immunizations?
Patient Name:_________________________________ Inflammatory Bowel Disease Medical Exam Questionnaire
Women Only
Are you sexually active? Yes_____ No _____
Form of birth control: _______________
Have you ever had a Pap smear? Yes_____ No _____ Don’t know _____
When was your last Pap smear? Date __________
Have you ever had a sexually transmitted disease? Yes_____ No _____ Don’t know _____
Have you ever had genital warts? Yes_____ No _____ Don’t know _____
Have you ever had an abnormal pap smear result? Yes_____ No _____ Don’t know _____
Have you ever had a mammogram? Yes_____ No _____ Don’t know _____
Abnormal mammogram Yes_____ No _____ Don’t know _____
Number of Pregnancies _____ Number of miscarriages ______
Have you taken oral contraceptives? Yes_____ No _____ Don’t know _____
Men Only
Are you sexually active? Yes_____ No _____
Form of birth control: _______________
Have you ever had a sexually transmitted disease? Yes_____ No _____ Don’t know _____
Have you ever had genital warts? Yes_____ No _____ Don’t know _____
FAMILY HISTORY
Are you married or have a significant other? Yes______ No______ Brothers Health Problems?____________________________________________ Health Problems?____________________________________________ Health Problems?____________________________________________ Health Problems?____________________________________________ Children living ______ Age(s)_____________ Health Problems?___________________________________ Children dead _______ Age(s) _____________ Health Problems?____________________________________ Please circle illness(es) which have occurred in any of your blood relatives: Patient Name:_________________________________ Inflammatory Bowel Disease Medical Exam Questionnaire REVIEW OF SYSTEMS
Mark the appropriate response if any of the following has been a problem recently:

Source: http://www.digestive.vcu.edu/docs/IBD_Questionnaire.pdf