Crohn's Disease Questionnaire


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Questionnaire

Required fields are indicated with a *

* Sex:

Male Female

* First name:

Surname:

Email address:

Confirm email address:

* Year when first diagnosed:

What is your current status:

* Please rate, on a scale of 1 to 5 (1 = does not impact at all, 5 = fully impacts) the extent to which your condition negatively impacts on your undertaking the following:

Socialising and meeting new people
1	2	3	4	5

Going on holidays/choosing holiday destinations
1	2	3	4	5

Shopping
1	2	3	4	5

Attending sporting/cultural/entertainment events
1	2	3	4	5

* If you are in employment, has your condition affected your career in any of the following ways. Tick true/false/not applicable:

I could not apply for/pursue a desired job/career
True	False	n/a

I had to change my job/career
True	False	n/a

I had to reduce my working hours
True	False	n/a

I did not go forward for promotion
True	False	n/a

* How aware is the following of your condition? Please rate on a scale of 1 to 5 (1 = not at all aware, 5 = fully aware) Please mark "not applicable" where appropiate.

Your partner
1	2	3	4	5	n/a

Your family
1	2	3	4	5	n/a

Your friends
1	2	3	4	5	n/a

Your employer
1	2	3	4	5	n/a

Your co-workers/students in your class at school/college
1	2	3	4	5	n/a

* Please rate, on a scale of 1 to 5 how well you feel you are coping with your condition right now (1 = very poorly; 5 = very well)


1	2	3	4	5

* On what aspect(s) of your condition would you like more information? (tick as many as apply)

a.	Coping at Work
b.	Travelling
c.	Support Groups
d.	Managing Diets
e.	Weight Issues
f.	Remembering Medications
g.	Other (please state)

Tick this box if you would like to be informed of special services from this website to help you manage your condition

Tick this box if you would you like to find out more about the Irish Society for Colitis and Crohn's Disease

* How did you find out about the Crohn's Clinic

Search Engine eg. Google
My Doctor/Nurse
Friend/Colleague
Media

* Please enter the code displayed in the image below in the box to the right:
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