Fiona Stanley Fremantle Hospitals Group - Inflammatory Bowel Disease (IBD) Questionnaire

Many thanks for taking a couple of minutes to complete this pre-clinic online questionnaire.

The information you provide will help your doctor treat your condition and address your concerns. The information we collect is confidential and is stored securely.

This questionnaire is for patients who have already been diagnosed with Inflammatory Bowel Disease (IBD).

If you believe you may have IBD but have not yet been diagnosed, please speak to you Doctor or GP to be diagnosed.

Once you have been diagnosed, you are then welcome to return to complete this questionnaire. Thank you.

Have you been diagnosed with Inflammatory Bowel Disease (IBD) ? Please select your category of IBD diagnosis

You have selected 'Other', Please specify:

What is your normal weight? (in kg's) What is your current height? (in cm's) Are you CURRENTLY taking any of the following medications? Infliximab (Remicade/Inflectra) Adalimumab (Humira) Vedolizumab (Entyvio) Ustekinemab (Stelara) None of the above Have you PREVIOUSLY taken any of the following medications? Infliximab (Remicade/Inflectra) Adalimumab (Humira) Vedolizumab (Entyvio) Ustekinemab (Stelara) None of the above Please tick or list any other medications you are currently taking for Inflammatory Bowel Disease? Budesonide (Entocort, Budenofalk, Cotiment) Prednisolone (Predsolone, Solone, Panafcortolone) Sulfasalazine (Pyralin, Salazopyrin) Mesalazine (Asacol, Mesazal, Mezavant, Pentasa, Salofalk) Azathioprine (Azapin, Imazan, Imuran, Thioprine) 6-mercaptopurine (Almercap, Purinethol) Methotrexate (Hospira, Methacord, Methoblastin) Allopurinol (Progout, Zyloprim) Other (Please specify) None of the above

Please specify 'Other' medications you are currently taking for IBD ?

If you are able, please list other medications you are taking In the last 6 months how often do you forget to take your medications? Never Rarely Sometimes Often Most of the time

Ulcerative ColitisWHEN YOU ARE WELL, how many bowel motions do you have per day? With regards to stool frequency, in the last 3 days I have experienced A normal number of stools per day 1 to 2 stools per day more than normal 3 to 4 stools per day more than normal 5 or more stools per day more than normal With regards to rectal bleeding, in the last 3 days I have experienced No blood in my stool Streaks of blood with stool less than half of the time Obvious blood with stool most of the time Blood alone passed

Crohn’s DiseaseIN THE LAST WEEK on average, how many LIQUID stools have you had each day? IN THE LAST WEEK ON AVERAGE, please rate your ABDOMINAL PAIN for each day? 0 - None 1 - Intermediate 2 - Intermediate 3 - Severe IN THE LAST WEEK ON AVERAGE, please rate your general well-being for each day? 0 - Well 1 - Intermediate 2 - Intermediate 3 - Intermediate 4 - Terrible In the last 7 days have you experienced ? (if unsure then select No) Joint aches, pains or inflammation Yes No Eye aches, itching, scratching or inflammation Yes No Skin or mouth lesions/ulcers Yes No Anal pain, fissures, fistulas or inflammation Yes No Any other fistulas (passages between the skin and the bowel) Yes No Fevers higher than 37.8oC Yes No In the last 7 days have you used anti-diarrhoea medications (e.g. loperamide, gastrostop, codeine) ? Yes No

Do you have any particular concerns or issues that you wish to discuss in your appointment (e.g. pain, quality of life issues, medications, family planning, etc) ? Approximate date of your last colonoscopy (as best you can remember)? If someone were to look inside your bowel TODAY, do you think they would find active inflammation? Yes No Are you interested in taking part in clinical trials into new treatments for inflammatory bowel disease? Yes No