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  2. 2011
  3. October
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  5. Adults
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What is your age?
   
 
 
 
Have you ever been diagnosed with Crohn's disease?
 
Yes
 
No
 
Unsure
 
 
 
Have you ever had oral problems such as oral ulcers that were attributed to oral Crohn's disease? (Indicate yes, no, or unsure and feel free to comment further.)
   
 
 
 
What prescription medications are you currently taking?
   
 
 
 
How often do you see a dentist?
 
At least once per month
 
At least once every 3 months
 
At least once every 6 months
 
Less than once every 6 months
 
 
 
When was your last dental visit?
 
Within the last week
 
Within the last month
 
Within the last 3 months
 
Over 3 months ago
 
 
 
What was the purpose of your last dental visit?
   
 
 
 
What oral or facial symptoms do you currently have (Select all that apply)?
 
Painful mouth sores
 
Swollen lips or cheeks
 
Red or swollen gums
 
Weakness in facial muscles
 
None
 
Other
 

 
 
 
Have you ever had any of these oral or facial symptoms in the past? If so, please explain which symptoms and when you experienced them.
   
 
 
 
Have you had trouble pronouncing any words because of problems with your teeth, mouth or dentures?
 
Never
 
Hardly ever
 
Occasionally
 
Fairly often
 
Very often
 
 
 
Have you felt that your sense of taste has worsened because of problems with your teeth, mouth or dentures?
 
Never
 
Hardly ever
 
Occasionally
 
Fairly often
 
Very often
 
 
 
Have you had painful aching in your mouth?
 
Never
 
Hardly ever
 
Occasionally
 
Fairly often
 
Very often
 
 
 
Have you found it uncomfortable to eat any foods because of problems with your teeth, mouth or dentures?
 
Never
 
Hardly ever
 
Occasionally
 
Fairly often
 
Very often
 
 
 
Have you been self-conscious because of your teeth, mouth or dentures?
 
Never
 
Hardly ever
 
Occasionally
 
Fairly often
 
Very often
 
 
 
Have you felt tense because of problems with your teeth, mouth or dentures?
 
Never
 
Hardly ever
 
Occasionally
 
Fairly often
 
Very often
 
 
 
Has your diet been unsatisfactory because of problems with your teeth, mouth or dentures?
 
Never
 
Hardly ever
 
Occasionally
 
Fairly often
 
Very often
 
 
 
Have you had to interrupt meals because of problems with your teeth, mouth or dentures?
 
Never
 
Hardly ever
 
Occasionally
 
Fairly often
 
Very often
 
 
 
Have you found it difficult to relax because of problems with your teeth, mouth or dentures?
 
1. Never
 
2. Hardly ever
 
3. Occasionally
 
4. Fairly often
 
5. Very often
 
 
 
Have you been a bit embarrassed because of problems with your teeth, mouth or dentures?

 
1. Never
 
2. Hardly ever
 
3. Occasionally
 
4. Fairly often
 
5. Very often
 
 
 
Have you been irritable with other people because of problems with your teeth, mouth or dentures?
 
1. Never
 
2. Hardly ever
 
3. Occasionally
 
4. Fairly often
 
5. Very often
 
 
 
Have you had difficulty doing your usual jobs because of problems with your teeth, mouth or dentures?
 
1. Never
 
2. Hardly ever
 
3. Occasionally
 
4. Fairly often
 
5. Very often
 
 
 
Have you felt that life in general was less satisfying because of problems with your teeth, mouth or dentures?

 
1. Never
 
2. Hardly ever
 
3. Occasionally
 
4. Fairly often
 
5. Very often
 
 
 
Have you been totally unable to function because of a problem with your teeth, mouth or dentures?
 
1. Never
 
2. Hardly ever
 
3. Occasionally
 
4. Fairly often
 
5. Very often
 
 
 
Please rate your general well being yesterday:
 
I felt very well
 
I felt slightly below par
 
I felt poor
 
I felt very poor
 
I felt terrible
 
 
 
Did you have any abdominal pain yesterday?
 
I had none
 
I had abdominal pain that was mild
 
I had abdominal pain that was moderate
 
I had abdominal pain that was severe
 
 
 
How many liquid stools did you have yesterday?
 
 
 
Do you have any of the following complications (select all that apply):
 
Arthralgia (pain in a joint)
 
Uveitis (red, painful eye/s)
 
Erythema nodosum (red, swollen bumps on the shin)
 
Pyoderma grangrenosum (oozing ulcers, usually on the legs)
 
Anal fissure
 
New fistula
 
Abscess

 
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