Crohn's Disease Patient's Questionaire

by Manor and Amir
(Israel)

Hello,

We are students of medical faculty in "Rothberg" high school, Ramat-Hasharon, Israel.
As a part of our study, we are conducting a research about Krohn's disease.
We appreciate your cooperation and willingness to answer the following questionnaire, that would help us in our research.
we attach herewith a questionaire and kindly ask you to mark yes or no for the yes no questions and answer the other questions with full answers. kindly send them by email to Manor.
We would like to emphasize that the questionnaire anonymous, and the data is used for the purpose of the research only.
we would like to express again our deep appreciation and thank you in advance for your cooperation.

sincerely yours,

Manor and Amir.

Manor's emaill:manornir@bezeqint.net

Questionnaire for Krohn patients:

*Age:
*Gender: Male/Female
*Profession:
*Weight:
*Height:
*Marital Status: Married/Divorced/Widow
*At what age did the disease appear for the first time?

*Do you suffer from diarrhea? Yes/No
*If yes – at what frequency?

*Do you suffer from abdominal pain? Yes/No
*If yes – at what frequency?

*Do you suffer from fever? Yes/No
*If yes – at what frequency?

*Did you lose weight since the break of the disease? Yes/No
*If yes – How much did you lose?

*Does the disease relapse due to emotional stress? Yes/No
*Does the disease relapse due to eating certain kinds of food? Yes/No
*If yes – what kind?

*Please rate the severity of your relapses on a scale of 1-5:
*Does the severity of your relapses change? Yes/No
*If yes, in what way?

*Before the break of the disease, did you suffer from arthritis? (Y/N) eye inflammations? (Y/N) skin rashes? (Y/N)
*Is there history of Krohn/Colitis in your family? (Y/N)
*If yes, in which family member?

*What were the initial symptoms of your disease?

*Are you familiar with methods of prevention of the disease? (Y/N)
*If yes, what are they?

*Do you act according to these methods? (Y/N)
*If yes, in what way?

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