UIcerative Colitis

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UIcerative Colitis

Personal Details:

UC 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

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

Wage Loss Due to Diseases Per Month (Rs.)

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Days Absent from Work Per Month

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Money Spent for Treatment Per Month (Rs.)

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Other Socio-Economic Information

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Clinical Details:

Age at Symptom Onset

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Duration of Illness (Months)

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Interval Between Onset of Symptoms and Diagnosis (Months)

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Clinical Features:

Features	Present	Duration (In Months)	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
Mucus in stool	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
Urgency	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
Pain Abdomen	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
Fistula	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
Bleeding PR	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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Extra Intestinal Features:

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
Isolated 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
Arthalgias	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
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
Hepatic Steatosis	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
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

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Chronic Continuous active Disease

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Relapsing and Remitting Disease (Intermittent Flares)

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Increase in the Severity of Disease after Initial Low Activity

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Fulminant Course (Early Colectomy)

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Disease Categorization:

Extent at Presentation

Severity at Presentation

Age at Presentation

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Male Patient - Offspring:

Any Period of Infertility

Yes

Total Offspring/s

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Offspring/s Since IBD Onset

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Remarks

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Physical Examination:

General Survey

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Anemia

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Oedema

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Jaundice

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Peripheral LNs

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Skin Rash

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Positive Other Findings

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Abdominal Examination:

Other System:

Lab Investigations:

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Baseline:

Parameters	Values
Hb
TC
DC
Platelet Count
MCV
MCHC
MCH
Ferritin
TIBC
Transfusion Saturation
Iron
Folic acid level
Vit B12 level
Hepcidin Level
Others

Parameters	Values
CRP
Urea
Creatinine
Total Bilirubin
Conjugated Bilirubin
Albumin
Globumin
SGPT
SGOT
ALP
GGT
FPG
PPPG
HbAIC
Na +
K+
T3
T4
TSH

Parameters	Values
P-Time
INR
APTT

Parameters	Values
HBs As
Anti HCV
HIV1 and HIV2
Cl. Difficele Toxin
CMV Positivity	Yes No Hematoxylin Eosin Stain Tissue PCR For CMV Serum PCR For CMV Tissue immunohistochemistry

Parameters	Values
Fecal Calprotectin Level

Parameters	Values

1^st Follow Up:

Parameters	Values
Hb
TC
DC
Platelet Count
MCV
MCHC
MCH
Ferritin
TIBC
Transfusion Saturation
Iron
Folic acid level
Vit B12 level
Hepcidin Level
Others

Parameters	Values
CRP
Urea
Creatinine
Total Bilirubin
Conjugated Bilirubin
Albumin
Globumin
SGPT
SGOT
ALP
GGT
FPG
PPPG
HbAIC
Na +
K+
T3
T4
TSH

Parameters	Values
P-Time
INR
APTT

Parameters	Values
HBs As
Anti HCV
HIV1 and HIV2

Parameters	Values
Cl. Difficele Toxin
CMV Positivity
HPE+VC
Tissue PCR
Serum PCR
Tissue Immuno Histology

Parameters	Values
Fecal Calprotectin Level

Parameters	Values

2^nd Follow Up:

Parameters	Values
Hb
TC
DC
Platelet Count
MCV
MCHC
MCH
Ferritin
TIBC
Transfusion Saturation
Iron
Folic acid level
Vit B12 level
Hepcidin Level
Others

Parameters	Values
CRP
Urea
Creatinine
LFT
Total Bilirubin
Conjugated Bilirubin
Albumin
Globumin
SGPT
SGOT
ALP
FPG
PPPG
HbAIC
Na +
K+
T3
T4
TSH

Parameters	Values
P-Time
APIT

Parameters	Values
HBs As
Anti HCV
HIV1 and HIV2

Parameters	Values
Cl. Difficele Toxin
CMV PCR

Parameters	Values
RE
ME
Fecal Calprotectin Level

Parameters	Values

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Colonoscopic Scores:

Add Follow Up

Baseline

Colonoscopy Date

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Findings

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Baron Score

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Mayo Endoscopic Score

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UCEIS

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Disease Extent

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Remarks

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1^st Follow Up

Colonoscopy Date

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Findings

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Baron Score

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Mayo Endoscopic Score

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UCEIS

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Disease Extent

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Remarks

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2^nd Follow Up

Colonoscopy Date

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Findings

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Baron Score

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Mayo Endoscopic Score

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UCEIS

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Disease Extent

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Remarks

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