Crohn's Disease

User Name

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Crohn's Disease

Personal Details:

CD ID. No.

Please provide a UC ID. No.

Patient Name

Patient Age

Gender

Present Address 1

Present Address 2

City / Village

Police Station

Pin Code

District

State

Country

Present Phone No.

Alternative Phone No.

Present Active Phone No.

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Patient Socio Economic Status:

Religion

Marital Status

Single

Married

Number of Children

Occupation

Diet

Vegetarian

Non-Vegetarian

Relative With IBD

Yes

No. of Relatives With UC

No. of Relatives With CD

Modified Kuppuswamy Socioeconomic Scale: 2022 Update of India

Total Monthly Income of the Family.

SL. NO.	Updated Monthly Family Income in Rupees (2022)	Score
1	≥ 185,895	12
2	92951-185894	10
3	69535-92950	6
4	46475-69534	4
5	27883-46474	3
6	9308-27882	2
7	≤ 9307	1

Occupation of the Head of the Family.

SL. NO.	Parameters	Score
Education
1	Professional Degree	7
2	Graduate	6
3	Intermediate / Diploma	5
4	High School	4
5	Middle School	3
6	Primary School	2
7	Illiterate	1

SL. NO.	Parameters	Score
Occupation
1	Professional	10
2	Semi-Professional	6
3	Clerical / Shop / Farmer	5
4	Skilled Worker	4
5	Semi-Skilled Worker	3
6	Unskilled Worker	2
7	Unemployed	1

Modified Kuppuswamy Socioeconomic Scale Score

Days Absent from Work Per Month (Rs.)

Please provide a valid Weight

Wage Loss Due to Diseases Per Month (Rs.)

Please provide a valid Height

Money Spent for Treatment Per Month (Rs.)

Please provide a valid Weight

Socio-Economic Information

Please provide a valid BMI.

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Clinical Details:

Age at Symptom Onset

Please provide a valid Height

Duration of Symptoms (Months)

Please provide a valid Weight

Interval Between Onset of Symptoms and Diagnosis (Months)

Please provide a valid BMI.

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Clinical Features:

Features	Present	Duration	Remarks
Diarrhea	Yes No	Please provide a valid Weight	Please provide a valid Height
Constipation	Yes No	Please provide a valid Weight	Please provide a valid Height
Bleeding PR	Yes No	Please provide a valid Weight	Please provide a valid Height
Hematochezia	Yes No	Please provide a valid Weight	Please provide a valid Height
Melena	Yes No	Please provide a valid Weight	Please provide a valid Height
Anasarca	Yes No	Please provide a valid Weight	Please provide a valid Height
Tenesmus	Yes No	Please provide a valid Weight	Please provide a valid Height
Fecal Urgency	Yes No	Please provide a valid Weight	Please provide a valid Height
Abdominal Pain	Yes No	Please provide a valid Weight	Please provide a valid Height
Gola Formation	Yes No	Please provide a valid Weight	Please provide a valid Height
Partial Intestinal Obstruction (PIO)	Yes No	Please provide a valid Weight	Please provide a valid Height
Weight Loss	Yes No	Please provide a valid Weight	Please provide a valid Height
Fever	Yes No	Please provide a valid Weight	Please provide a valid Height
Loss of Appetite	Yes No	Please provide a valid Weight	Please provide a valid Height
Vomiting	Yes No	Please provide a valid Weight	Please provide a valid Height
Entero-cutaneous Fistula	Yes No	Please provide a valid Weight	Please provide a valid Height
Perianal Fistula	Yes No	Please provide a valid Weight	Please provide a valid Height
Recto Urethral Fistula	Yes No	Please provide a valid Weight	Please provide a valid Height
Recto Vaginal Fistula	Yes No	Please provide a valid Weight	Please provide a valid Height
Entero-visical Fistula	Yes No	Please provide a valid Weight	Please provide a valid Height
Vesico Urethral Fistula	Yes No	Please provide a valid Weight	Please provide a valid Height
IBS Like Symptom	Yes No	Please provide a valid Weight	Please provide a valid Height
Lethargy Weakness	Yes No	Please provide a valid Weight	Please provide a valid Height
Peripheral Edema	Yes No	Please provide a valid Weight	Please provide a valid Height
Others		Please provide a valid Weight	Please provide a valid Height

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Perianal Disease:

Features	Present	Duration	Remarks
Hemorrhoids	Yes No	Please provide a valid Weight	Please provide a valid Height
Fissure	Yes No	Please provide a valid Weight	Please provide a valid Height
Perianal Fistula	Yes No	Please provide a valid Weight	Please provide a valid Height
Peri-anal Skin Tags	Yes No	Please provide a vali	Please provide a valid
Peri-anal Skin Tags Type 1	Yes No	Please provide a valid Weight	Please provide a valid Height
Peri-anal Skin Tags Type 2	Yes No	Please provide a valid Weight	Please provide a valid Height
Anal Stricture	Yes No	Please provide a valid Weight	Please provide a valid Height
Anal Ulcers	Yes No	Please provide a valid Weight	Please provide a valid Height
Others		Please provide a valid Weight	Please provide a valid Height

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Extraintestinal Symptoms During Remission:

EIM	Present	After Onset of IBD	Remarks
Erythema Nodosum	Yes No	Yes No	Please provide a valid Height
Pyoderma Gangrenosum	Yes No	Yes No	Please provide a valid Height
Psoriasis	Yes No	Yes No	Please provide a valid Height
Oral Apthous Ulcers	Yes No	Yes No	Please provide a valid Height
Sarcoilitis HLA B27	Yes No	Yes No	Please provide a valid Height
Ankylosing Spondylitis HLA B27	Yes No	Yes No	Please provide a valid Height
Arthralgias	Yes No	Yes No	Please provide a valid Height
Type 1 Arthritis (Pauciarticular)	Yes No	Yes No	Please provide a valid Height
Type 2 Arthritis (Polyarticiular > 5 Symmetirical)	Yes No	Yes No	Please provide a valid Height
Redness of Eyes: Episcleritis	Yes No	Yes No	Please provide a valid Height
Redness of Eyes: Uveitis	Yes No	Yes No	Please provide a valid Height
Redness of Eyes: Iritis	Yes No	Yes No	Please provide a valid Height
Gall Stone	Yes No	Yes No	Please provide a valid Height
Autoimmune Hepatitis	Yes No	Yes No	Please provide a valid Height
Pancreatitis	Yes No	Yes No	Please provide a valid Height
Fatty Liver	Yes No	Yes No	Please provide a valid Height
Renal Stones	Yes No	Yes No	Please provide a valid Height
PSC	Yes No	Yes No	Please provide a valid Height
Thrombotic Episodes	Yes No	Yes No	Please provide a valid Height
Others			Please provide a valid Height

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Course of Disease:

Single Episode of Relapse Followed by Prolonged Remission

Please provide a valid Height

Chronic Continuous active Disease

Please provide a valid Weight

Relapsing and Remitting Disease (Intermittent Flares)

Please provide a valid BMI.

Increase in the Severity of Disease after Initial Low Activity

Please provide a valid BMI.

Fulminant Course (Early Colectomy)

Please provide a valid BMI.

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Disease Categorization:

Extent at Presentation

Severity at Presentation

Age at Presentation

Please provide a valid BMI.

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Male Patient - Offspring:

Any Period of Infertility

Yes

No. of Months

Total Offspring/s

Please provide a valid BMI.

Offspring/s Since IBD Onset

Please provide a valid BMI.

Remarks

Please provide a valid BMI.

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Physical Examination:

General Survey

Please provide a valid BMI.

Abdominal Examinations

Please provide a valid BMI.

Peri-anal Examination

Please provide a valid BMI.

Other Symptoms

Please provide a valid BMI.

Skin and Mucous Membranes

Please provide a valid BMI.

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Lab Investigations:

Add Follow Up

Baseline:

Parameters	Biochemical
Hb
Packed Cell
TC
DC - N [%]
DC - L [%]
DC - E [%]
DC - M [%]
DC - B [%]
Platelet CT
MCV
MCHC
MCH
Ferritin
TIBC
Transfusion Saturation
S. Iron
Folic Acid Level
Vit B12 Level
Hepcidin Level
RDW [%]
Corrected Reticulocyte Count
Others

Parameters	Biochemical
CRP
Urea
Creatinine
Total Protein
Total Bilirubin
Conjugated Bilirubin
UC. Bilirubin
Albumin
Globumin
SGPT
SGOT
ESR
ALP
FPG
PPPG
HbAIC
Na +
K+
T3
T4
TSH

Parameters	Biochemical
P-Time
INR
APTT

Parameters	Biochemical
HBsAg (Pos / Neg)
Anti HCV (Pos / Neg)
HIV (Pos / Neg)
Cl. Difficele Toxin (Pos / Neg)
Anti CMV Antibody
CMV PCR

Parameters	Biochemical
Fecal Calprotectin Level

Parameters	Biochemical

1^st Follow Up:

Parameters	Biochemical
Hb
Packed Cell
TC
DC - N [%]
DC - L [%]
DC - E [%]
DC - M [%]
DC - B [%]
Platelet CT
MCV
MCHC
MCH
Ferritin
TIBC
Transfusion Saturation
S. Iron
Folic Acid Level
Vit B12 Level
Hepcidin Level
RDW [%]
Corrected Reticulocyte Count
Others

Parameters	Biochemical
CRP
Urea
Creatinine
Total Protein
Total Bilirubin
Conjugated Bilirubin
UC. Bilirubin
Albumin
Globumin
SGPT
SGOT
ESR
ALP
FPG
PPPG
HbAIC
Na +
K+
T3
T4
TSH

Parameters	Biochemical
P-Time
APTT

Parameters	Biochemical
HBsAg (Pos / Neg)
Anti HCV (Pos / Neg)
HIV (Pos / Neg)
Cl. Difficele Toxin (Pos / Neg)
Anti CMV Antibody
CMV PCR

Parameters	Biochemical
Fecal Calprotectin Level

Parameters	Biochemical

2^nd Follow Up:

Parameters	Biochemical
Hb
Packed Cell
TC
DC - N
DC - L
DC - E
DC - M
DC - B
Platelet CT
MCV
MCHC
MCH
Ferritin
TIBC
Transfusion Saturation
S. Iron
Folic Acid Level
Vit B12 Level
Hepcidin Level
RDW [%]
Corrected Reticulocyte Count
Others

Parameters	Biochemical
CRP
Urea
Creatinine
Total Protein
Total Bilirubin
Conjugated Bilirubin
UC. Bilirubin
Albumin
Globumin
SGPT
SGOT
ESR
ALP
FPG
PPPG
HbAIC
Na +
K+
T3
T4
TSH

Parameters	Biochemical
P-Time
APTT

Parameters	Biochemical
HBsAg (Pos / Neg)
Anti HCV (Pos / Neg)
HIV (Pos / Neg)
Cl. Difficele Toxin (Pos / Neg)
Anti CMV Antibody
CMV PCR

Parameters	Biochemical
Fecal Calprotectin Level

Parameters	Biochemical

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Biochemistry:

Add Follow Up

Baseline:

Parameters	Biochemical
Hb
TC
DC
Platelet Count
Urea
Creatinine
Total Protein
Albumin
Globumin
Total Bilirubin
Conjugated Bilirubin
UC. Bilirubin
ALP
SGPT
SGOT
CRP
ESR
FPG
PPPG
HbAIC
Na +
K+
T3
T4
TSH
P-Time
APTT
HBsAg (Pos / Neg)
Anti HCV (Pos / Neg)
HIV(Pos / Neg)
C. Difficile Toxin (Pos / Neg)
Anti CMV Antibody
CMV PCR

1^st Follow Up:

Parameters	Biochemical
Hb
TC
DC
Platelet Count
Urea
Creatinine
Total Protein
Albumin
Globumin
Total Bilirubin
Conjugated Bilirubin
UC. Bilirubin
ALP
SGPT
SGOT
CRP
ESR
FPG
PPPG
HbAIC
Na +
K+
T3
T4
TSH
P-Time
APTT
HBsAg (Pos / Neg)
Anti HCV (Pos / Neg)
HIV(Pos / Neg)
C. Difficile Toxin (Pos / Neg)
Anti CMV Antibody
CMV PCR

2^nd Follow Up:

Parameters	Biochemical
Hb
TC
DC
Platelet Count
Urea
Creatinine
Total Protein
Albumin
Globumin
Total Bilirubin
Conjugated Bilirubin
UC. Bilirubin
ALP
SGPT
SGOT
CRP
ESR
FPG
PPPG
HbAIC
Na +
K+
T3
T4
TSH
P-Time
APTT
HBsAg (Pos / Neg)
Anti HCV (Pos / Neg)
HIV(Pos / Neg)
C. Difficile Toxin (Pos / Neg)
Anti CMV Antibody
CMV PCR

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Stool:

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Baseline:

Parameters	Value
Fecal Calprotectin Level

1^st Follow Up:

Parameters	Value
Fecal Calprotectin Level

2^nd Follow Up:

Parameters	Value
Fecal Calprotectin Level

Global Histologic Disease Activity Score (GHAS):

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Baseline:

Parameter	Histopathology Findings	Score/Grade
What was the anatomical location from which the specimen was collected?	Ileum Right colon Transverse colon Left colon Rectum
Epithelial damage	Normal Focal pathology Extensive pathology
Architectural changes	Normal Moderately disturbed (<50%) Severely disturbed (>50%)
Infiltration of mononuclear cells in the lamina propria	Normal Moderate increas Severe increase
Infiltration of polymorphonuclear cells in the lamina propria	Normal Moderate increase Severe increase
Polymorphonuclear cells in epithelium	Normal In surface epithelium Cryptitis Crypt abscess
Presence of erosion and/or ulcers	No Yes
Presence of granuloma	No Yes
Number of biopsy specimens affected	None ≤33% 33% - 66% >66%

1^st Follow Up:

Parameter	Histopathology Findings	Score/Grade
What was the anatomical location from which the specimen was collected?	Ileum Right colon Transverse colon Left colon Rectum
Epithelial damage	Normal Focal pathology Extensive pathology
Architectural changes	Normal Moderately disturbed (<50%) Severely disturbed (>50%)
Infiltration of mononuclear cells in the lamina propria	Normal Moderate increas Severe increase
Infiltration of polymorphonuclear cells in the lamina propria	Normal Moderate increase Severe increase
Polymorphonuclear cells in epithelium	Normal In surface epithelium Cryptitis Crypt abscess
Presence of erosion and/or ulcers	No Yes
Presence of granuloma	No Yes
Number of biopsy specimens affected	None ≤33% 33% - 66% >66%

2^nd Follow Up:

Parameter	Histopathology Findings	Score/Grade
What was the anatomical location from which the specimen was collected?	Ileum Right colon Transverse colon Left colon Rectum
Epithelial damage	Normal Focal pathology Extensive pathology
Architectural changes	Normal Moderately disturbed (<50%) Severely disturbed (>50%)
Infiltration of mononuclear cells in the lamina propria	Normal Moderate increas Severe increase
Infiltration of polymorphonuclear cells in the lamina propria	Normal Moderate increase Severe increase
Polymorphonuclear cells in epithelium	Normal In surface epithelium Cryptitis Crypt abscess
Presence of erosion and/or ulcers	No Yes
Presence of granuloma	No Yes
Number of biopsy specimens affected	None ≤33% 33% - 66% >66%

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Radiology of Perianal Disease:

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Baseline:

Date

MRI Pelvis Fistulogram

ACG

Park Classification

No of Fistula Openings

No of Fistula Freels

1^st Follow Up:

Date

MRI Pelvis Fistulogram

ACG

Park Classification

No of Fistula Openings

No of Fistula Freels

2^nd Follow Up:

Date

MRI Pelvis Fistulogram

ACG

Park Classification

No of Fistula Openings

No of Fistula Freels

MRI OR CT Scan:

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Baseline:

Parameter	Present
Site	Small Bowel: Not Investigated Jejunal Ileum Jejunal and Ileum Not Evaluated
	Large Bowel: Not Investigated Rectum Sigmoid Transverse Colon Ascending Colon Caecum Not Evaluated
	Ileocecal Junction: Isolated Terminal Ileal Involvement Ileocecal Involvement Normal IC Valve Deformed IC Valve Not Evaluated
Lymph Nodes	Absent Present
	Mesentric Recto-peritoneal Both
	Necrosis: Absent Present
	Size: < 1cm > 1cm
Involved Segment	Wall Thickening: Absent Concentric Asymmetric Not Evaluated
	Mural Stratification: Absent Present Not Evaluated
	Continuity of lesion: Contiguous Skip Not Evaluated
	Stricture: Short Long Not Evaluated
	Fistula: Absent Present Not Evaluated
	Fistula Type: Enteroenteric Enterocolic Colocolic Colovesical Enterovesical Enterovaginal
Mesenteric / Peritoneal changes	Mesenteric: Absent Fibrofatty Proliferation Comb Sign Both Not Evaluated
	Peritoneal Changes: Non Peritoneal Thickening Peritoneal Nodularity Ascites Not Evaluated
	Abscess: Absent Present Not Evaluate

1^st Follow Up:

Parameter	Present
Site	Small Bowel: Not Investigated Jejunal Ileum Jejunal and Ileum Not Evaluated
	Large Bowel: Not Investigated Rectum Sigmoid Transverse Colon Ascending Colon Caecum Not Evaluated
	Ileocecal Junction: Isolated Terminal Ileal Involvement Ileocecal Involvement Normal IC Valve Deformed IC Valve Not Evaluated
Lymph Nodes	Absent Present
	Mesentric Recto-peritoneal Both
	Necrosis: Absent Present
	Size: < 1cm > 1cm
Involved Segment	Wall Thickening: Absent Concentric Asymmetric Not Evaluated
	Mural Stratification: Absent Present Not Evaluated
	Continuity of lesion: Contiguous Skip Not Evaluated
	Stricture: Short Long Not Evaluated
	Fistula: Absent Present Not Evaluated
	Fistula Type: Enteroenteric Enterocolic Colocolic Colovesical Enterovesical Enterovaginal
Mesenteric / Peritoneal changes	Mesenteric: Absent Fibrofatty Proliferation Comb Sign Both Not Evaluated
	Peritoneal Changes: Non Peritoneal Thickening Peritoneal Nodularity Ascites Not Evaluated
	Abscess: Absent Present Not Evaluate

2^nd Follow Up:

Parameter	Present
Site	Small Bowel: Not Investigated Jejunal Ileum Jejunal and Ileum Not Evaluated
	Large Bowel: Not Investigated Rectum Sigmoid Transverse Colon Ascending Colon Caecum Not Evaluated
	Ileocecal Junction: Isolated Terminal Ileal Involvement Ileocecal Involvement Normal IC Valve Deformed IC Valve Not Evaluated
Lymph Nodes	Absent Present
	Mesentric Recto-peritoneal Both
	Necrosis: Absent Present
	Size: < 1cm > 1cm
Involved Segment	Wall Thickening: Absent Concentric Asymmetric Not Evaluated
	Mural Stratification: Absent Present Not Evaluated
	Continuity of lesion: Contiguous Skip Not Evaluated
	Stricture: Short Long Not Evaluated
	Fistula: Absent Present Not Evaluated
	Fistula Type: Enteroenteric Enterocolic Colocolic Colovesical Enterovesical Enterovaginal
Mesenteric / Peritoneal changes	Mesenteric: Absent Fibrofatty Proliferation Comb Sign Both Not Evaluated
	Peritoneal Changes: Non Peritoneal Thickening Peritoneal Nodularity Ascites Not Evaluated
	Abscess: Absent Present Not Evaluate

Radiological Investigations:

UGI Endoscopy:

Add Follow Up

Baseline:

Date

Findings

1^st Follow Up:

Date

Findings

2^nd Follow Up:

Date

Findings

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Colonoscopy And Terminal Ileoscopy:

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Baseline:

Date

Findings

1^st Follow Up:

Date

Findings

2^nd Follow Up:

Date

Findings

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DBE:

Add Follow Up

Baseline:

Date

Findings

Date

WCE

Findings

1^st Follow Up:

Date

Findings

Date

WCE

Findings

2^nd Follow Up:

Date

Findings

Date

WCE

Findings

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SES CD:

	Ileum	Right Colon	Transverse Colon	Left Colon	Rectum
Number of segments with ulcerations
Presence of ulcerations 0=None 1=Aphthous (<0.5cm) 2=Large (0.5-2cm) 3=Very large (>2cm)
Extent of ulcerations 0=None 1=<10% 2=10-30% 3=>30%
Affected surface 0=Unaffected 1=<50% 2=50-75% 3=>75%
Presence of strictures 0=None 1=Single, can be passed 2=Multiple, can be passed 3=Cannot be passed
SES-CD
MM-SES-CD

Colonoscopy SES - CD:

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1st Follow Up:

Date	Findings	SES CD Score

2nd Follow Up:

Date	Findings	SES CD Score

3rd Follow Up:

Date	Findings	SES CD Score

Nutritional Assessments:

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Baseline:

Date

Weight Change

Dietary Intake

Gastrpomtestinal Symptoms

Functional Capacity

Co-Morbidity

Decreased Fat Stores

Muscle Wasting

Subjective Global Assessment Score

Reference

1^1st Follow Up:

Date

Weight Change

Dietary Intake

Gastrpomtestinal Symptoms

Functional Capacity

Co-Morbidity

Decreased Fat Stores

Muscle Wasting

Subjective Global Assessment Score

Reference

2^nd Follow Up:

Date

Weight Change

Dietary Intake

Gastrpomtestinal Symptoms

Functional Capacity

Co-Morbidity

Decreased Fat Stores

Muscle Wasting

Subjective Global Assessment Score

Reference

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Clinical Follow Up:

Add Follow Up

1^st Follow Up

Date of Visit

No. of Visits

Please provide a valid BMI.

HBI

Please provide a valid BMI.

CDAI

Please provide a valid BMI.

CRP

Please provide a valid BMI.

Fecal Calprotetin

Please provide a valid BMI.

Weight

Please provide a valid BMI.

Presents Symptoms (PRO)

Please provide a valid BMI.

VAS

Please provide a valid BMI.

No of Frequency

Please provide a valid BMI.

Bleeding

Please provide a valid BMI.

New Symptoms

Please provide a valid BMI.

Extra Intestinal Manifestation

Please provide a valid BMI.

Disease Activity

Please provide a valid BMI.

Admission

Yes

Drug at Present

Please provide a valid BMI.

Drug Related AEs

Please provide a valid BMI.

Drug Modification

Please provide a valid BMI.

Drug Added

Please provide a valid BMI.

Present Montreal Classification

Please provide a valid BMI.

Remarks

Please provide a valid BMI.

2^nd Follow Up

Date of Visit

No. of Visits

Please provide a valid BMI.

HBI

Please provide a valid BMI.

CDAI

Please provide a valid BMI.

CRP

Please provide a valid BMI.

Fecal Calprotetin

Please provide a valid BMI.

Weight

Please provide a valid BMI.

Presents Symptoms (PRO)

Please provide a valid BMI.

VAS

Please provide a valid BMI.

No of Frequency

Please provide a valid BMI.

Bleeding

Please provide a valid BMI.

New Symptoms

Please provide a valid BMI.

Extra Intestinal Manifestation

Please provide a valid BMI.

Disease Activity

Please provide a valid BMI.

Admission

Yes

Drug at Present

Please provide a valid BMI.

Drug Related AEs

Please provide a valid BMI.

Drug Modification

Please provide a valid BMI.

Drug Added

Please provide a valid BMI.

Present Montreal Classification

Please provide a valid BMI.

Remarks

Please provide a valid BMI.

3^rd Follow Up

Date of Visit

No. of Visits

Please provide a valid BMI.

HBI

Please provide a valid BMI.

CDAI

Please provide a valid BMI.

CRP

Please provide a valid BMI.

Fecal Calprotetin

Please provide a valid BMI.

Weight

Please provide a valid BMI.

Presents Symptoms (PRO)

Please provide a valid BMI.

VAS

Please provide a valid BMI.

No of Frequency

Please provide a valid BMI.

Bleeding

Please provide a valid BMI.

New Symptoms

Please provide a valid BMI.

Extra Intestinal Manifestation

Please provide a valid BMI.

Disease Activity

Please provide a valid BMI.

Admission

Yes

Drug at Present

Please provide a valid BMI.

Drug Related AEs

Please provide a valid BMI.

Drug Modification

Please provide a valid BMI.

Drug Added

Please provide a valid BMI.

Present Montreal Classification

Please provide a valid BMI.

Remarks

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Past History of Surgery:

No of Surgeries in the Past for CD:

Post 1st Surgery

Time to Endoscopic Recurrence (Month)

Time to Clinical Recurrence (Month)

Time to Surgical Recurrence (Month)

Remarks

Please provide a valid BMI.

Post 2nd Surgery

Time to Endoscopic Recurrence (Month)

Time to Clinical Recurrence (Month)

Time to Surgical Recurrence (Month)

Remarks

Please provide a valid BMI.

Post 3rd Surgery

Time to Endoscopic Recurrence (Month)

Time to Clinical Recurrence (Month)

Time to Surgical Recurrence (Month)

Remarks

Please provide a valid BMI.

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User Name

Crohn's Disease

Personal Details:

Patient Socio Economic Status:

Modified Kuppuswamy Socioeconomic Scale: 2022 Update of India

Total Monthly Income of the Family.

Occupation of the Head of the Family.

Epidemiological:

Baseline:

Height & Weight

Smoking

Tobacco Chewing

Alcohol

Comorbid Illness

Others

1st Follow Up:

Height & Weight

Smoking

Tobacco Chewing

Alcohol

Comorbid Illness

Others

2nd Follow Up:

Height & Weight

Smoking

Tobacco Chewing

Alcohol

Comorbid Illness

Others

Clinical Details:

Clinical Features:

Perianal Disease:

Extraintestinal Symptoms During Remission:

Course of Disease:

Disease Categorization:

Female Patient - Offspring:

Mother

1st Pregnancy

Baby

2nd Pregnancy

Baby

3rd Pregnancy

Baby

Male Patient - Offspring:

Physical Examination:

Lab Investigations:

Baseline:

Hematological

Biochemistry

Coagulation

Infection

Stool

Other Lab Investigation

1st Follow Up:

Hematological

Biochemistry

Coagulation

Infection

Stool

Other Lab Investigation

2nd Follow Up:

Hematological

Biochemistry

Coagulation

Infection

Stool

Other Lab Investigation

Biochemistry:

Baseline:

1st Follow Up:

2nd Follow Up:

Stool:

Baseline:

1st Follow Up:

2nd Follow Up:

Global Histologic Disease Activity Score (GHAS):

Baseline:

1st Follow Up:

2nd Follow Up:

Radiology of Perianal Disease:

1^st Follow Up:

2^nd Follow Up:

1^st Pregnancy

2^nd Pregnancy

3^rd Pregnancy

1^st Follow Up:

2^nd Follow Up:

1^st Follow Up:

2^nd Follow Up:

1^st Follow Up:

2^nd Follow Up:

1^st Follow Up:

2^nd Follow Up:

1^st Follow Up:

2^nd Follow Up:

1^st Follow Up:

2^nd Follow Up:

1^st Follow Up:

2^nd Follow Up:

1^st Follow Up:

2^nd Follow Up:

1^st Follow Up:

2^nd Follow Up:

1^1st Follow Up:

2^nd Follow Up:

1^st Follow Up

2^nd Follow Up

3^rd Follow Up