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IBD Registry, CD Initial Visit Date: _ _ / _ _ / _ _
[ patient sticker ]
Registration Information
Date of Birth: _ _ / _ _ / _ _
Gender: o Male o FemaleTelephone #: (_ _ _) - _ _ _ - _ _ _ _
Attending MD: ______
Year of IBD diagnosis: _ _ _ _
Demographic and Family History Information
Hispanic: o Yes o No
Race:o White
oBlack/African American
oAsian
oAmerican Indian/Alaskan Native
oNative Hawaiian/Pacific Islander
oMore than one race
oOther (specify: ______)
oUnknown
IBD Affected
CDUCType UnclearUnaffectedUnknown
Father:______
Mother:______
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):
oYeso Ex-Smokero Noo Unknown
If yes or ex-smoker: Year started: _ _ _ _ Year stopped: _ _ _ _
Macroscopic Disease Location (check all that apply):
Upper GI:o Yes o Noo UnknownColon:o Yes o Noo Unknown
Jejunal:o Yes o Noo UnknownPerianal:o Yes o Noo Unknown
Ileal:o Yes o Noo Unknown
Surgery
Surgery for complication or treatment of CD: o Yeso Noo Unknown
If yes:
YearType of procedure
____o Resection and primary anast.o Resection, primary anast., and protective stoma
o Resection and stomao Stoma
Resection of:o Stomacho Duodenumo Jejunumo Ileum
o NeoTIo Appendixo Cecumo Ascending
o Transverseo Descending o Sigmoido Rectum
If stoma:Type:o Ileostomyo Colostomy
Other procedures:o Stricturoplastyo Abd abscess drainage
o I&D perianalo Perianalfistulotomy
o Seton placemento Stoma revision
o Advancement flapo Other
o IPAA
YearType of procedure
____o Resection and primary anast.o Resection, primary anast., and protective stoma
o Resection and stomao Stoma
Resection of:o Stomacho Duodenumo Jejunumo Ileum
o NeoTIo Appendixo Cecumo Ascending
o Transverseo Descending o Sigmoido Rectum
If stoma:Type:o Ileostomyo Colostomy
Other procedures:o Stricturoplastyo Abd abscess drainage
o I&D perianalo Perianalfistulotomy
o Seton placemento Stoma revision
o Advancement flapo Other
o IPAA
If more surgeries, please attach additional sheets.
Extraintestinal Manifestations & Complications:o Yes o Noo Unknown
If yes:
Joint symptoms related to disease activity:o Yes o Noo Unknown
Ankylosingspondylitis/sacro-ileitis:o Yes o Noo Unknown
Erythemanodosum:o Yes o Noo Unknown
Pyoderma:o Yes o Noo Unknown
Oral aphthous ulcers:o Yes o Noo Unknown
Ocular inflammation:o Yes o Noo Unknown
Osteoporosis/osteopenia:o Yes o Noo Unknown
Liver disease:
PSC:o Yes o Noo Unknown
Other:o Yes o Noo Unknown
Pouchitis:o Yes o Noo Unknown
Cancer and Dysplasia
Year of Dx
Non-GI
Cancer:o Yeso Noo Unknown_ _ _ _
Dysplasia:o Yeso Noo Unknown_ _ _ _
Lymphoproliferative disorder:o Yeso Noo Unknown_ _ _ _
GI excluding CRC
Cancer:o Yeso Noo Unknown_ _ _ _
Lymphoproliferative disorder:o Yeso Noo Unknown_ _ _ _
CRC or Dysplasia of colon:
Dysplasia:o Yeso Noo Unknown_ _ _ _
CRC:o Yeso Noo Unknown_ _ _ _
Gender Specific Issues:
Ever pregnant:o Yeso Noo Unknowno Not applicable
Infertility (the inability to naturally conceive a child or the inability to carry a pregnancy to term):
o Yeso Noo Unknowno Not applicable
IBD Studies:
Currently enrolled in therapeutic IBD study:o Yeso Noo Unknown
List trial: ______
Previously enrolled in therapeutic IBD study: o Yeso Noo Unknown
List trial: ______
Current Medications:
Corticosteroids (topical or oral):o Yeso Noo Unknown
Aminosalicylates (topical or oral): o Yeso Noo Unknown
6MP/Azathioprine:o Yeso Noo Unknown
Methotrexate:o Yeso Noo Unknown
Calcineurin inhibitor:o Yeso Noo Unknown
Antibiotics:o Yeso Noo Unknown
Anti-TNF:o Yeso Noo Unknown
Alpha-4-integrin inhibitor:o Yeso Noo Unknown
IBD Serologies:
IBD serologies performed:o Yeso Noo Unknown