New survey – IBD LIFE Index

IBD LIFE Index

With this questionnaire, we want to assess whether you can live a normal life with your inflammatory bowel disease.

Patient number(Required)

A. Physical aspects(Required)

In the past 2 weeks, to what extent has your life been impaired by:

	0 Not at all	1 Mildly	2 Moderately	3 Severely	4 Extremely
Abdominal pain
Anal or perianal problems
Fecal urgency ((Difficulty controlling bowel movements, including rushing to the toilet, staying near the toilet, fecal incontinence))
Poor sleep
Fatigue
Flare-up of your bowel disease

B. Activities(Required)

In the past 2 weeks, to what extent has your disease impaired:

	0 Not at all	1 Mildly	2 Moderately	3 Severely	4 Extremely
Physical care ((Please rate the overall impact of your disease on the following activities: washing, dressing and undressing, toileting))
Activities ((Please rate the overall impact of your disease on the following activities: housekeeping, walking, grocery shopping, hobbies, exercise))
Travel ((Including vacation and daily transportation))

C. Social aspects(Required)

In the past 2 weeks, to what extent has your disease impaired:

D. Psychological aspects(Required)

In the past 2 weeks, to what extent has your disease impaired:

	0 Not at all	1 Mildly	2 Moderately	3 Severely	4 Extremely
Life satisfaction ((Life satisfaction involves how content you are with your life with your bowel disease))
Outlook on the future ((Outlook on the future involves how hopeful you are about your future with your bowel disease))
Autonomy ((Autonomy involves how independent you feel))
Resilience ((Resilience involves your ability to cope with stress or adversity))
Self-confidence
Feeling in control of your complaints

E. Circumstances(Required)

In the past 2 weeks, to what extent has your life been impaired by:

	0 Not at all	1 Mildly	2 Moderately	3 Severely	4 Extremely
Surgical procedure ((Any past surgery that still impairs your life to this day, including any surgery more than two weeks ago that negatively impacted your life in the past two weeks))
Hospitalization ((Including one-day hospitalization for IV therapy, an endoscopy or a minor surgical procedure. This may be any past hospitalization that still impairs your life to this day, including any hospitalization more than 2 weeks ago that negatively impacted your life in the past two weeks))
Inability to take out health insurance

	0 Not at all	1 Mildly	2 Moderately	3 Severely	4 Extremely
Income loss due to inability to work (full-time) ((Are you a student or retired? Skip this question))

F. On a scale of 0-100, to what extent has your disease impaired your life in the past 2 weeks?

G. Do you feel you know enough about your bowel disease?(Required)

Yes

No

H. What is the main thing you would like to discuss today with your health care professional:(Required)

Remarks: