IBD Patient Questionnaire

Please read the information below and then complete the questionnaire:

The American College of Gastroenterology (ACG) has created guidelines to address preventative care for people who have Inflammatory Bowel Disease (IBD).

People who have IBD are at a greater risk for many vaccine-preventable illnesses, including

Influenza
Pneumonia
Shingles

Immunosuppressive medications further increase the risk.

People with IBD are also at higher risk of melanoma and some medications used to treat IBD can increase the risk of non-melanoma skin cancers.

Continued tobacco use can cause increased inflammation in the colon in certain patients with IBD.

Exposure to medications such as prednisone and budesonide can increase the risk of osteoporosis in people with IBD.

Women with IBD who are takin immunosuppressive medications have a higher risk of cervical cancer.

Lastly, people with IBD are at higher risk for anxiety and depression.

The ACG guidelines outline interventions to lessens these risks, including:

Vaccines
Skin check with dermatology
Smoking cessation
Bone density testing
Annual cervical cancer screening
Screening for anxiety and depression

Your answers to the questions below will help your provider create an individualized health maintenance plan for you based on your history and current medications.

IBD Patient Questionnaire

Name

Vaccines:

1. Have you ever received any of the following vaccines:

Influenza (Flu) Fall 2021/Winter 2022

Yes No I am not sure

COVID 19 vaccine

Yes No I am not sure

If yes to the COVID 19 vaccine:

Moderna Pfizer Johnson & Johnson

How many doses?

One Two Three

Pneumococcal Vaccine (Pneumonia)

Yes No I am not sure

Shingrex Vaccine (shingles)

Yes No I am not sure

2. Approximate date of last visit with dermatology:

3. Have you been prescribed prednisone (or Budesonide/Entocort) in the past for your inflammatory bowel disease?

Yes No

4. Have you ever had a DEXA scan (bone density) in the past?

Yes No

5. Do you smoke cigarettes?

Yes No

PHQ - 9: Over the past two week how often have you been bothered by the following:

1. Little interest or pleasure in doing things

0 [ Not at all ] 1 [ Several days ] 2 [ More than half the days ] 3 [ Nearly everyday ]

2. Feeling down, depressed, or hopeless

0 [ Not at all ] 1 [ Several days ] 2 [ More than half the days ] 3 [ Nearly everyday ]

3. Trouble falling or staying asleep

0 [ Not at all ] 1 [ Several days ] 2 [ More than half the days ] 3 [ Nearly everyday ]

4. Feeling tired or having little energy

0 [ Not at all ] 1 [ Several days ] 2 [ More than half the days ] 3 [ Nearly everyday ]

5. Poor appetite or overeating

0 [ Not at all ] 1 [ Several days ] 2 [ More than half the days ] 3 [ Nearly everyday ]

6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down

0 [ Not at all ] 1 [ Several days ] 2 [ More than half the days ] 3 [ Nearly everyday ]

7. Trouble concentrating on things, such as reading the newspaper or watching television

0 [ Not at all ] 1 [ Several days ] 2 [ More than half the days ] 3 [ Nearly everyday ]

8. Moving or speaking so slowly that other people could have noticed? Or so fidgety or restless that you have been moving a lot more than usual

0 [ Not at all ] 1 [ Several days ] 2 [ More than half the days ] 3 [ Nearly everyday ]

9. Thoughts that you would be better off dead, or thoughts of hurting yourself in some way

0 [ Not at all ] 1 [ Several days ] 2 [ More than half the days ] 3 [ Nearly everyday ]

GAD- 7: Over the past two week how often have you been bothered by the following:

Feeling nervous, anxious, or on edge

0 [ Not at all ] 1 [ Several days ] 2 [ More than half the days ] 3 [ Nearly everyday ]

Not being able to stop or control worrying

0 [ Not at all ] 1 [ Several days ] 2 [ More than half the days ] 3 [ Nearly everyday ]

Worrying too much about different things

0 [ Not at all ] 1 [ Several days ] 2 [ More than half the days ] 3 [ Nearly everyday ]

Trouble relaxing

0 [ Not at all ] 1 [ Several days ] 2 [ More than half the days ] 3 [ Nearly everyday ]

Being so restless that it's hard to sit still

0 [ Not at all ] 1 [ Several days ] 2 [ More than half the days ] 3 [ Nearly everyday ]

Becoming easily annoyed or irritable

0 [ Not at all ] 1 [ Several days ] 2 [ More than half the days ] 3 [ Nearly everyday ]

Feeling afraid as if something awful might happen

0 [ Not at all ] 1 [ Several days ] 2 [ More than half the days ] 3 [ Nearly everyday ]

Please answer the three questions below and give this form to the MA or provider:

1. I feel confident that making sure I am up to date with annual health maintenance will help decrease my risk of cancer.

1 (I do not feel confident at all) 2 3 4 5 (I feel very confident)

2. After reading the information about annual health maintenance for patients with Inflammatory Bowel Disease, I am better informed to make a decision about needed vaccines, blood work, or imaging with my provider.

1 (I am not well informed) 2 3 4 5 (I am very informed)

3. After completing the PHQ - 9 and GAD - 7 (the above tools for screening of anxiety and depression), I feel that my provider is addressing my increased risk for a mood disorder given my history of Inflammatory Bowel Disease.

1 (I do not feel my provider is addressing my risk) 2 3 4 5 (I am confident my provider is addressing my risk)

Your information will be encrypted.

Loading...