1. Patient personal details
Insurance number:…………………………..
Name:…………………………………………
Date of birth:…………………………………….
Contact number:………………………………..
Gender: Female / Male
Ethnicity/Race: White / Roma / Black / Indian / Asian / Other: …….
Blood type: 0 / A / AB / B RH: positive / negative
Allergie: yes/no, if yes:………………………………
Time of questioning: ………………………………(year, month, day)
Was written consent given? Yes / No
Way of admission: ambulatory/ hospital admission
Patient was admitted for: acute flare of symptoms / scheduled testing or intervention
If the patient was admitted:
Date of admittance:
Date of discharge:
Length of hospital stay:
2. Details from the medical history / Risk factors
Smoking: Yes / No
if yes: amount (cigarettes/day):…………………
For how many years? …………………………
if not:
Did you smoke earlier? yes/no
if yes: amount (pcs/occasion):…………………………………
For how many years?………………………………………
How long ago did you stop smoking? ……………………………….
Alcohol consumption: yes / no
if yes: frequency: occasionally/monthly/weekly/daily
amount (g/day):…………………………………
since when? (years):………………………….
Alcohol consumption in the last 2 weeks: …………………..
if not:
Did you drink alcohol earlier? yes/no
if yes: frequency: occasionally/monthly/weekly/daily
amount (g/occasion):…………………………………
For how many years?………………………………………
How long ago did you stop drinking alcohol?..........................
Country:
City:
Hospital:
Doctor:
Blood sample code:
Date of blood sampling:
Guide for estimation of the amount:
1 dl beer (4.5 vol. %) = ~3.5 g alcohol
1 dl wine (12.5 vol. %) = ~10 g alcohol
1 dl hard drink (50 vol. %) = ~40 g alcohol
Caffeine consumption : yes /no
If yes, in what form do you consume caffeine?
Coffe: yes / no
If yes, how often do you consume coffee? occasionally/monthly/weekly/daily
How much do you consume?....................................
(1 dose = one espresso or long coffe)
Instant Coffee: yes / no
If yes, how often do you consume instant coffee? occasionally/monthly/weekly/daily
How much do you consume?....................................
(1 dose = one packet)
Tee (black or green): yes / no
If yes, how often do you consume tee? occasionally/monthly/weekly/daily
How much do you consume?....................................
(1 dose =2 dl)
Energy drink: yes / no
If yes, how often do you consume energy drink ? occasionally/monthly/weekly/daily
How much do you consume?....................................
(1 dose = 2,5 dl)
Coca-cola: yes / no
If yes, how often do you consume coca-cola? occasionally/monthly/weekly/daily
How much do you consume?....................................
(1 dose =3,3 dl)
Caffeine tablet: yes / no
If yes, how often do you consume caffeine tablet? occasionally/monthly/weekly/daily
How many do you consume?....................................
(1 dose =1 tablet= 100 mg)
Drug abuse: yes/no Prescribed medication should not be included here.
If yes, what kind of drug did you consume?
Party drugs: (pl. Amfetamin, Ecstasy, Gina, Mefedron): yes/no
If yes, how much did you take? …………………How many years ago?……………
Light drugs: (LSD, Marihuana, Hasis): yes/no
If yes, how much did you take? …………………How many years ago?……………
Hard drugs: (Crack, Heroin, Kokain, Ópium): yes/no
If yes, how much did you take? …………………How many years ago?……………
Medicines: (Diazepám, Ketamin, Kodein): yes/no
If yes, how much did you take? …………………How many years ago?……………
Designer drugs: (Mefedron, szintetikus cannabinoidok): yes/no
If yes, how much did you take? …………………How many years ago?……………
Diabetes mellitus: yes/no
If Yes: type I. / type II / type III. / MODY
Date of diagnose (date: year)……………………………….
Oral contraceptive usage: yes/no
If yes, when did you take oral contraceptives? before IBD diagnosis/ at the time of IBD
diagnosis
If yes, total duration of Oral contraceptive usage………. (in months)
NSAID usage (longer than 2 weeks): yes/no
If yes, when did you take NSAID? before IBD diagnosis/ at the time of IBD
diagnosis/currently
Usage of antibiotics: yes/no
If yes, when did you take NSAID? before IBD diagnosis/ at the time of IBD
diagnosis/currently
Appendectomy: yes/no
If yes, when did you have appendectomy? ..................................... (date: year)
Previous surgeries not related to IBD: yes/no
If yes, 1. type of surgery:...........................date of surgery:......................(year, month)
2. type of surgery:...........................date of surgery:......................(year, month)
Family history: first degree realtive: Yes / No
If Yes: relative 1. UC / CD, which relative: father / mother / sibling / child
relative 2. UC / CD, which relative: father / mother / sibling / child
Highest level of education: elementary school / vocational school /secondary school / college
/ university
Comorbidities:
Comorbidity 1. :…………………….
Date of diagnosis:…………(year)
drug treatment: Yes / No
if yes, name(s) and dose(s) of the used medication(s) :………………………
surgical treatment: Yes / No
If yes, type of surgery:……………….
Comorbidity 2. :…………………….
Date of diagnosis:…………(year)
drug treatment: Yes / No
if yes, name(s) and dose(s) of the used medication(s) :………………………
surgical treatment: Yes / No
If yes, type of surgery:……………….
Autoimmun disease? Yes / No
If Yes, the diagnosis: Hashimoto thyreoiditis /Addison-syndroma/ Sjögren-
syndrome/ Szisztémás lupus erythematosus (SLE)/ Rheumatoid arthritis (RA)/ coeliakia/
other:……
3. Data on the diagnosis
Date of diagnosis (year, month): ……………………………
Start of symptoms (year, month): ………………………......
Patient’s age at the diagnosis: ………………
The name of the gastroenterologist who established the diagnosis:…………………………
The workplace of the gastroenterologist who established the diagnosis:
hospital (county/urban) /clinic / polyclinic / private practice
Where did the patient live at the time of the diagnosis? city / village
Diagnosis was based on:
3.1. Symptoms: Yes / No
If yes, symptoms occurring at the time of the diagnosis:
abdominal pain / nausea / vomiting / subfebrility / fever / loss of weight / diarrhea / bloody stool/
mucous stool/ fistula / extraintestinal manifestation
If there was extraintestinal manifestation, name it: eye symptom / skin symptom / joint symptom
/ thromboembolism / osteororosis / liver symptom
CD with fistula: Yes / No
If yes,
type os the Fistula: simple / complex
localization of the Fistula: perianal / rectovaginal / entero-enteral / enterocutan /
enterovesical
Determination of Fistula Type: physical state / endoscopy/ images of the pelvic: (MRI /
Ultrasound)/ EUA: rectal examination in anesthesia
Number of fistula:………(piece)
3.2. Laboratory findings: Yes / No
If yes, laboratory findings at the time of the diagnosis: elevated CRP / elevated WBC /
accelerated ESR/ anaemia / iron deficiency / abnormal liver functions / low albumine level
3.3. Endoscopy: Yes / No
Date of the first endoscopy (on which the diagnose was based):………...(year, month)
(uploading result is mandatory)
* quality checkpoint*
Ileo-colonoscopy: Yes / No
If yes, affected segment (s) of the bowels: Ileum / right colon /colon transversum /left
colon / Rectum (description can be attached)
Stricture: Yes / No
If yes, the lovalisation of the stricture: Ileum / right colon /colon transversum /left colon
/ Rectum
Oesophagogastroduodenoscopy: Yes / No
If yes, affected segment (s) of the bowels: esophagus / gastric /duodenum (description can
be attached)
If yes, the lovalisation of the stricture: esophagus / gastric /duodenum
Capsule Endoscopy: Yes / No
If yes, findings:……………… (description can be attached)
3.4. Histological findings: Yes / No (description can be attached)
3.5. Imaging findings: Yes / No
Abdominal ultrasound: Yes / No / no data
If yes, the result: negative / abnormality
Name the abnormality: free abdominal fluid / thickness of the intestinal wall /
abscess / bowel conglomerate / abnormality of the liver / other (e.g: tumor)
The localization of the intestinal wall thickness: duodenum/ small bowels /
coecum/colon ascendens/ colon transversum/ colon descendens/ sigmoid
Name the abnormality of the liver: dilatation of the bile ducts / diffuse lesion of
the liver parenchyma
(description can be attached)
Abdominal X-ray: Yes / No / no data
If yes, the result: negative / abnormality
Name the abnormality: perforation /ileus / passage disturbance/ other (e.g: tumor)
Abdominal CT: Yes / No / no data
If yes, the result: negative / abnormality
Name the abnormality: free abdominal fluid / thickness of the intestinal wall /
abscess / bowel conglomerate / abnormality of the liver / other (e.g: tumor)
The localization of the intestinal wall thickness: duodenum/ small bowels /
coecum/colon ascendens/ colon transversum/ colon descendens/ sigmoid
Name the abnormality of the liver: dilatation of the bile ducts / diffuse lesion of
the liver parenchyma
(description can be attached)
CT-enterography/enteroclysis: Yes / No
If yes, findigs:……………………………. (description can be attached)
Abdominal MRI: Yes / No / no data
If yes, the result: negative / abnormality
Name the abnormality: free abdominal fluid / thickness of the intestinal wall /
abscess / bowel conglomerate / abnormality of the liver / other (e.g: tumor)
The localization of the intestinal wall thickness: duodenum/ small bowels /
coecum/colon ascendens/ colon transversum/ colon descendens/ sigmoid
Name the abnormality of the liver: dilatation of the bile ducts / diffuse lesion of
the liver parenchyma
(description can be attached)
MR-enterography/enteroclysis: Yes / No
If yes, findigs:……………………………. (description can be attached)
MRCP: Yes / No / no data
If yes, the result: negative / abnormality
Name the abnormality: intrahepatic PSC / extrahepatic PSC / chronic pancreatitis
/ cholangiocarcinoma
Liver biopsy: Yes / No / no data
If yes, the result: negative / abnormality
Name the abnormality: PSC /cholangiocarcinoma/ steatosis hepatis / other (e.g:
tumor)
EUS (rectal): Yes / No / no data
If yes, the result: negative / abnormality
Name the abnormality: fistula / abscess/ other (e.g: tumor)
3.6. IBD related surgical interventions: Yes / No / no data
If yes,
1. type of the surgery: Proctocolectomy + IPAA / proctocolectomy + ileostomy / right
hemicolectomia + ileumresection / segmental resection / stricturo-plastica / abscess
exploration / fistulotomy / seton drenage/ fistulotomy +seton drenage
The localisation of the resection:………………..
Description of the surgery:…………………… (description can be attached)
Histology:………………………… (description can be attached)
2. type of the surgery: Proctocolectomy + IPAA / proctocolectomy + ileostomy / right
hemicolectomia + ileumresection / segmental resection / stricturo-plastica / abscess
exploration / fistulotomy / erspdrenage/ fistulotomy +seton drenage
The localisation of the resection:………………..
Description of the surgery:…………………… (description can be attached)
Histology:………………………… (description can be attached)
Montreal classification at the time of the diagnosis:
Age: A1: under 17 years / A2: between 17 and 40 years / A3: over 40 years
Localisation: L1: ileum / L2: colon / L3: ileum and colon / L4: isolated upper GI
Behavior: B1: non- stricturing, non- penetrating / B2: stricturing / B3: penetrating
4. Events since the establishment of a diagnosis
How many gastroenterologist have treated the patient so far? ……………(piece)
If the diagnosis was established in the childhood, how did the patient get to the adult
gastroenterologist?
transitional care: Yes / No
If yes, the number of joint visits: …(piece)
transfer: Yes / No
If yes, did telephone consultation happened between the pediatrician and the adult
gastroenterologist? Yes / No
Did the patient have any relapse since the establishment of the diagnosis? (apart from the
disease activity at the time of diagnosis)? Yes / No
If yes, how many rekapse did the patient have? 1/ 2/ 3/ more than 3
In case of more than 3 relapses, the exact number of relapses:……..(piece)
Did the Montreal classification change sincet he diagnosis? Yes / No
Age: A1: under 17 years / A2: between 17 and 40 years / A3: over 40 years
Localisation: L1: ileum / L2: colon / L3: ileum and colon / L4: isolated upper GI
Behavior: B1: non- stricturing, non- penetrating / B2: stricturing / B3: penetrating
4.1. Therapy (Therapeutic stairs)
Did the patient get 5-ASA drugs? Yes / No
Has any adverse reaction / side effect occurred during the therapy? Yes / No
If yes: allergy / intolerance / nausea / abdominal pain / diarrhea / nephritis / rash of the
skin/ Sweet syndrome / headache /arthralgia /myalgia / Bone marrow depression /
hepatitis / pneumonitis
Did the patient have to stop taking the treatment? Yes / No
If yes, the reason for stopping the treatment: side effect/ adverse reaction/ patient’s
choice/ other: ………
If yes, the date of discontinuation of the treatment: ………. (year, month)
Did the patient get Steroids? Yes / No
Budesonid: Yes / No
If yes, how many times:…….
Methylprednisolon/ prednisolon: Yes / No
If yes, how many times:………
Has any adverse reaction / side effect occurred during the therapy? Yes / No
If yes: edema / infection / Cushing syndrome / osteoporosis / diabetes / gastric
ulcer / depression / psychosis / glaucoma / cataracta / increased intracranial pressure/
hypokalaemia / thromboembolism / menstruational disorder / wound healing disorder /
muscle weakness / acute adrenal insufficiency
If there was an infection, what caused it: virus / bacterium/ fungal
Was the patient refractory to steroid treatment? Yes / No
Was the disease steroid-dependent? Yes / No
Did the patient get Immunsupressant drugs? Yes / No
Azathioprine: Yes / No
If yes, the initiation of the treatment:………………….. (year, month)
The date of discontinuation of the treatment: ………. (year, month)
Has any adverse reaction / side effect occurred during the therapy? Yes / No
If yes: nausea / vomiting / Bone marrow depression / leukopenia / elevation of
liver enzymes /pancreatitis
The highest applied dose: ……… mg/ttkg
Did the patient get the treatment on the highest applicable dose? Yes / No
If no, the reason for it: nausea / vomiting / Bone marrow depression / leukopenia
/ elevation of liver enzymes /pancreatitis
Did the patient have to stop taking the treatment? Yes / No
If yes, the reason for stopping the treatment: side effect/ adverse reaction/ patient’s
choice/ other: ………
The result of the Azatioprine treatment: effective / not effective
If it was effective, was the remission proved? Yes / No
If yes, how was the remission proved? endoscopy/ calprotectin/ images (name the image)
6-MP: Yes / No
If yes, the initiation of the treatment:………………….. (year, month)
The date of discontinuation of the treatment: ………. (year, month)
Has any adverse reaction / side effect occurred during the therapy? Yes / No
If yes: nausea / vomiting / Bone marrow depression / leukopenia / elevation of
liver enzymes /pancreatitis
The highest applied dose: ……… mg/ttkg
Did the patient get the treatment on the highest applicable dose? Yes / No
If no, the reason for it: nausea / vomiting / Bone marrow depression / leukopenia
/ elevation of liver enzymes /pancreatitis
Did the patient have to stop taking the treatment? Yes / No
If yes, the reason for stopping the treatment: side effect/ adverse reaction/ patient’s
choice/ other: ………
The result of the 6-MP treatment: effective / not effective
If it was effective, was the remission proved? Yes / No
If yes, how was the remission proved? endoscopy/ calprotectin/ images (name the image)
Methotrexate: Yes / No
If yes, the initiation of the treatment:………………….. (year, month)
Has any adverse reaction / side effect occurred during the therapy? Yes / No
if yes: Bone marrow depression / mucositis / alopecia / Liver toxicity
The highest applied dose: ……… mg/week
Did the patient have to stop taking the treatment? Yes / No
If yes, the reason for stopping the treatment: side effect/ adverse reaction/ patient’s
choice/ other: ………
If yes, The date of discontinuation of the treatment: ………. (year, month)
The result of the Methotrexate treatment: effective / not effective
If it was effective, was the remission proved? Yes / No
If yes, how was the remission proved? endoscopy/ calprotectin/ images (name the image)
Tacrolimus: Yes / No
If yes, the initiation of the treatment:………………….. (year, month)
Has any adverse reaction / side effect occurred during the therapy? Yes / No
If yes: opportunistic infection / deteriorating kidney functions / neurotoxicity /
hyperglykaemia/ gastrointestinal complaint
If there was any opportunistic infection: tuberculosis / fungal infections / other
The highest applied dose: ……… mg/week
Did the patient have to stop taking the treatment? Yes / No
If yes, the reason for stopping the treatment: side effect/ adverse reaction/ patient’s
choice/ other: ………
If yes, The date of discontinuation of the treatment: ………. (year, month)
The result of the Tacrolimus treatment: effective / not effective
If it was effective, was the remission proved? Yes / No
If yes, how was the remission proved? endoscopy/ calprotectin/ images (name the image)
Was the disease persistant despite the immunosuppressive treatment? Yes / No
If yes, did the patient get biological treatment? Yes / No
If yes, what was the first biological agent: Remicade / Inflectra / Humira /Entyvio / Stelara
If yes, the initiation of the treatment:………………….. (year, month)
What viewpoints were taken into account when choosing from the available biological drugs?
Patient’s preference / doctor’s preference / common decision / financing reasons / other:…..
Was there:
side effect/ adverse reaction: Yes / No
if yes: upper respiratory tract infection / tuberculosis / invasive fungal infection / hepatitis
B-reactivation / bakterial sepsis / infusion reaction
Primary nonresponse: Yes / No
Secondary loss of response: Yes / No
if yes, date: ……… (year, month)
cause of secondary loss of response: ………………………
Was dose escalation needed during the treatment? Yes / No
if yes, date: ….………(year, month)
Method of dose escalation? increase dose / increase frequency
How long did the patient get the raised dose?................... (year, month)
Was there a need for strating a non-biological drug beside the biological treatment? Yes / No
If yes, which drug was given? steroid/ immunomodulator/5-ASA
Was surgical intervention needed during the biological therapy? Yes / No
The result of the biological treatment: effective / healed mucosa / not effective
Did the patient have to stop the biological treatment? Yes / No
If yes, why: side effect / Primary nonresponse / Secondary loss of response / financing
reasons / other
Was there a need to change to a second biological therapy? Yes / No
If yes, the name of the chosen second biological therapy: Remicade / Inflectra / Humira /Entyvio
/ Stelara
If yes, the initiation of the treatment:………………….. (year, month)
What viewpoints were taken into account when choosing from the available biological drugs?
Patient’s preference / doctor’s preference / common decision / financing reasons / other:…..
Was there:
side effect/ adverse reaction: Yes / No
if yes: upper respiratory tract infection / tuberculosis / invasive fungal infection / hepatitis
B-reactivation / bakterial sepsis / infusion reaction
Primary nonresponse: Yes / No
Secondary loss of response: Yes / No
if yes, date: ……… (year, month)
cause of secondary loss of response: ………………………
Was dose escalation needed during the treatment? Yes / No
if yes, date: ….………(year, month)
Method of dose escalation? increase dose / increase frequency
How long did the patient get the raised dose?................... (year, month)
Was there a need for strating a non-biological drug beside the biological treatment? Yes / No
If yes, which drug was given? steroid/ immunomodulator/5-ASA
Was surgical intervention needed during the biological therapy? Yes / No
The result of the biological treatment: effective / healed mucosa / not effective
Did the patient have to stop the biological treatment? Yes / No
If yes, why: side effect / Primary nonresponse / Secondary loss of response / financing
reasons / other
Was there a need to change to a third biological therapy? Yes / No
Did the patient received biological agent in a clinical trial? Yes / No
If yes, the name of the test formula:………………………….
Did the patient receive any feeding formula? Yes / No
If yes, the way of formula intake: enteral/parenteral
If it was enteral nutrition, the type of enteral nutrition: exclusive enteral nutrition / additional
enteral nutrition
The name of the applied formula:………….Duration of the nutrition:………….. (months)
Was iron substitution needed? Yes / No
If yes, the name of the applied iron substitution:...........................
The way of intake: intravenous /per os
4.2. Endoscopy
The result of the last endoscopy since the diagnosis:
Ileo-colonoscopy:
The date of the endoscopy:………………………(year, month, day)
Indication of the endoscopy: appearance of acute symptoms / planned control examination /
planned intervention
Ileo-colonoscopy (SES-CD; simple endoscopic score for CD):
Ileum:
SES-CD score: evaluable If it is evaluable, the score is:…………….
not evaluable
If it is not evaluable, the reason: resected / can not be examined due to
stenosis / can not be examined due to technical reasons / contaminated
If the SES-CD score can not be detemined: inflammation/erosion/ulcer/stricture
Right colon: SES-CD score: evaluable If it is evaluable, the score is:…………….
not evaluable
If it is not evaluable, the reason: resected / can not be examined due to
stenosis / can not be examined due to technical reasons / contaminated
If the SES-CD score can not be detemined: inflammation/erosion/ulcer/stricture
Colon Transversum: SES-CD score: evaluable If it is evaluable, the score is:…………….
not evaluable
If it is not evaluable, the reason: resected / can not be examined due to
stenosis / can not be examined due to technical reasons / contaminated
If the SES-CD score can not be detemined: inflammation/erosion/ulcer/stricture
Left colon: SES-CD score: evaluable If it is evaluable, the score is:…………….
not evaluable
If it is not evaluable, the reason: resected / can not be examined due to
stenosis / can not be examined due to technical reasons / contaminated
If the SES-CD score can not be detemined: inflammation/erosion/ulcer/stricture
Rectum:
SES-CD score: evaluable If it is evaluable, the score is:…………….
not evaluable
If it is not evaluable, the reason: resected / can not be examined due to
stenosis / can not be examined due to technical reasons / contaminated
If the SES-CD score can not be detemined: inflammation/erosion/ulcer/stricture
Size of the ulcer (in cm): 0 – no ulcer, 1 –0,1-0,5 cm, 2- 0,5-2 cm, 3 –>2cm
Ulcerated surface: 0 – no ulcer, 1 - <10%, 2 – 10-30%, 3 - >30%
Surface affected: 0 – nincs, 1 - <50%, 2- 50-75%, 3 - >75%
Stricture: 0- no sticture, 1- one stricture, possible to get through, 2 –
more sticture, possible to get through, 3 – not possible to get
through
SES-CD score of the lower GI tract:……………….. pont
inactive: score 0–3; mild: score 4–10; moderately severe: score11–19; severe: score ≥20.
Operated intestines: Yes / No
If yes: Rutgeerts score (judgment of the endoscopic postoperative recurrence):
RS 0 – no endoscopic recurrence / RS 1 - ≤5 aphtosus lesion / RS 2 - >5 aphtosus lesion
/ RS 3 – diffuse aphtosus ileitis / RS 4 – diffuse inflammation with ulcers and/or stricture
Does the patient have stoma? Yes / No
Was the examination performed through the stoma? Yes / No
Pouchoscopia? Yes / No
If yes: Size of the ulcer (in cm): 0 – no ulcer, 1 –0,1-0,5 cm, 2- 0,5-2 cm, 3 –>2cm
Ulcerated surface: 0 – no ulcer, 1 - <10%, 2 – 10-30%, 3 - >30%
Surface affected: 0 – nincs, 1 - <50%, 2- 50-75%, 3 - >75%
Stricture: 0- no sticture, 1- one stricture, possible to get through, 2 –
more sticture, possible to get through, 3 – not possible to get
through
Oesophagogastroduodenoscopy
The date of the endoscopy:………………………(year, month, day)
Indication of the endoscopy: appearance of acute symptoms / planned control examination /
planned intervention
Oesophagogastroduodenoscopy (SES-CD): Yes / No
If yes:
Esophagus:
SES-CD score: evaluable If it is evaluable, the score is:…………….
not evaluable
If it is not evaluable, the reason: resected / can not be examined due to
stenosis / can not be examined due to technical reasons / contaminated
If the SES-CD score can not be detemined: inflammation/erosion/ulcer/stricture
Gastric:
SES-CD score: evaluable If it is evaluable, the score is:…………….
not evaluable
If it is not evaluable, the reason: resected / can not be examined due to
stenosis / can not be examined due to technical reasons / contaminated
If the SES-CD score can not be detemined: inflammation/erosion/ulcer/stricture
Duodenum:
SES-CD score: evaluable If it is evaluable, the score is:…………….
not evaluable
If it is not evaluable, the reason: resected / can not be examined due to
stenosis / can not be examined due to technical reasons / contaminated
If the SES-CD score can not be detemined: inflammation/erosion/ulcer/stricture
Size of the ulcer (in cm): 0 – no ulcer, 1 –0,1-0,5 cm, 2- 0,5-2 cm, 3 –>2cm
Ulcerated surface: 0 – no ulcer, 1 - <10%, 2 – 10-30%, 3 - >30%
Surface affected: 0 – nincs, 1 - <50%, 2- 50-75%, 3 - >75%
Stricture: 0- no sticture, 1- one stricture, possible to get through, 2 –
more sticture, possible to get through, 3 – not possible to get
through
SES-CD score of the upper GI tract:………………..pont
Histology: Yes / No (description can be attached)
Was endoscopic intervention performed? Yes / No / no data
If yes, was endoscopic dilatation performed? Yes / No
If yes, the localisation of the dilatated segment: rectum / colon /small intestines/
anastomosis / upper GIT
Was ERCP performed? Yes / No
If yes, the indication of the ERCP: choledocholithiasis / PSC / stricture
If yes, was any intervention performed? Yes / No
If yes, name the intervention: EST/endobiliar stent implantation
If stent was implanted, hogy many: ……. (piece)
4.3 Surgical interventions performed since the diagnosis
Surgeries Not related to IBD after the diagnosis Yes / No
If yes, 1. type of surgery:...........................date of surgery:......................(year, month)
2. type of surgery:...........................date of surgery:......................(year, month)
Surgeries related to IBD after the diagnosis Yes / No
If yes,
1. type of the surgery: Proctocolectomy + IPAA / proctocolectomy + ileostomy / right
hemicolectomia + ileumresection / segmental resection / stricturo-plastica / abscess
exploration / fistulotomy / seton drenage/ fistulotomy +seton drenage
The localisation of the resection:………………..
Description of the surgery:…………………… (description can be attached)
Histology:………………………… (description can be attached)
2. type of the surgery: Proctocolectomy + IPAA / proctocolectomy + ileostomy / right
hemicolectomia + ileumresection / segmental resection / stricturo-plastica / abscess
exploration / fistulotomy / seton drenage/ fistulotomy +seton drenage
The localisation of the resection:………………..
Description of the surgery:…………………… (description can be attached)
Histology:………………………… (description can be attached)
4.4. The last permormed imaging tests from the establishment of the diagnosis to the
present
Abdominal ultrasound: Yes / No / no data
If yes, the result: negative / abnormality
Name the abnormality: free abdominal fluid / thickness of the intestinal wall /
abscess / bowel conglomerate / abnormality of the liver / other (e.g: tumor)
The localization of the intestinal wall thickness: duodenum/ small bowels /
coecum/colon ascendens/ colon transversum/ colon descendens/ sigmoid
Name the abnormality of the liver: dilatation of the bile ducts / diffuse lesion of
the liver parenchyma
(description can be attached)
Abdominal X-ray: Yes / No / no data
If yes, the result: negative / abnormality
Name the abnormality: perforation /ileus / passage disturbance/ other (e.g: tumor)
Abdominal CT: Yes / No / no data
If yes, the result: negative / abnormality
Name the abnormality: free abdominal fluid / thickness of the intestinal wall /
abscess / bowel conglomerate / abnormality of the liver / other (e.g: tumor)
The localization of the intestinal wall thickness: duodenum/ small bowels /
coecum/colon ascendens/ colon transversum/ colon descendens/ sigmoid
Name the abnormality of the liver: dilatation of the bile ducts / diffuse lesion of
the liver parenchyma
(description can be attached)
CT-enterography/enteroclysis: Yes / No
If yes, findigs:……………………………. (description can be attached)
Abdominal MRI: Yes / No / no data
If yes, the result: negative / abnormality
Name the abnormality: free abdominal fluid / thickness of the intestinal wall /
abscess / bowel conglomerate / abnormality of the liver / other (e.g: tumor)
The localization of the intestinal wall thickness: duodenum/ small bowels /
coecum/colon ascendens/ colon transversum/ colon descendens/ sigmoid
Name the abnormality of the liver: dilatation of the bile ducts / diffuse lesion of
the liver parenchyma
(description can be attached)
MR-enterography/enteroclysis: Yes / No
If yes, findigs:……………………………. (description can be attached)
MRCP: Yes / No / no data
If yes, the result: negative / abnormality
Name the abnormality: intrahepatic PSC / extrahepatic PSC / chronic pancreatitis
/ cholangiocarcinoma
EUS (rectal): Yes / No / no data
Capsule Endoscopy: Yes / No
If yes, findings:……………… (description can be attached
4.5. Other additional event/examination since the diagnosis
Did the patient get transfusion? Yes / No
If yes, how many units:............... (piece)
Functional examinations: Yes / No
lactose intolerance:Yes / No
If yes, the result: positive/ negative
lactulose intolerance: Yes / No
If yes, the result: positive/ negative
other tests: Yes / No
If yes, the name of the test:………..
If yes, the result: positive/ negative
Did the patient visit psychologist? Yes / No
If yes, with what kind of problem did the patient go to the
psychologist?...........................................
Started medication: Yes / No
If yes, name and dose of the drug:………………….
Started non-medical treatment: Yes / No
If yes, name the non-medical treatment:……………………..
Was the patient vaccinated? Yes / No
If yes, what kind of vaccination did the patient get? flu/ HPV/ Hepatitis A/ Hepatitis B/
Pneumucoccus/Meningococcus/ticks encephalitis vaccine
Was Osteoporosis examined? (DEXA) Yes / No
ha igen, the result:………………… ………………
Started medication: Yes / No
If yes, name and dose of the drug:………………….
Other examination:........................ (name the examination)
TPMT genetics: TPMT*2 (G238C) / TPMT*3A (G460A)/ TPMT*3A (A719G)
Celiac disease immunserology: Yes / No
If yes, the result: positive/ negative
5. Current Data (At the time of the interview)
5.1. Currently taken medicines
If yes, the name of the drug:………..……….. active
substance:………….……dose:………………... (gramm, milligramm, packet, piece) how many
times per day/ week .................................. way of intake: …………………..(intravenous / per os
/ suppository/ enema)
Other comment: ………………………………………
If yes, the name of the drug:………..……….. active
substance:………….……dose:………………... (gramm, milligramm, packet, piece) how many
times per day/ week .................................. way of intake: …………………..(intravenous / per os
/ suppository/ enema)
Other comment: ………………………………………
If yes, the name of the drug:………..……….. active
substance:………….……dose:………………... (gramm, milligramm, packet, piece) how many
times per day/ week .................................. way of intake: …………………..(intravenous / per os
/ suppository/ enema)
Other comment: ………………………………………
Does the patient receive any feeding formula? Yes / No
If yes, the way of formula intake: enteral/parenteral
If it is enteral nutrition, the type of enteral nutrition: exclusive enteral nutrition / additional enteral
nutrition
The name of the applied formula:………….Duration of the nutrition:………….. (months)
Is iron substitution needed? Yes / No
If yes, the name of the applied iron substitution:...........................
The way of intake: intravenous /per os
Does the patient keep any kind of diet? Yes / No
If yes, what kind of diet does the patient keep? …..……………………
5.2. Status, present complaints
Weight (kg):……………
Std.weight (kg):……..
Height (m):……………
BMI (kg/m2)………………………………
Body temperature (°C):………..
Present complaints
Number of stool (per week):
Appearance of the stool: normal /bloody / mucous
Consistency of the stool: normal/ loose /hard/ diarrhea
Diarrhea at night? Yes / No
Abdominal complaint: none / cramping / distention / constant
pain
How long does the patient have abdominal complaints?
……………………….. (week)
Anal complaints? Yes / No
Nausea? Yes / No
Vomitting? Yes / No
Swallowing complaints? Yes / No
Breathing complaints? Yes / No
Chest complaints? Yes / No
Urogenital complaints? Yes / No
Conjunctiva? Anaemic / hyperemia/ normal
Edema? Yes / No
Icterus? Yes / No
Cyanosis? Yes / No
Loss of appetite? Yes / No
Loss of weight? Yes / No
Other complaint: …………… ……………………………………………
Activity of the luminális CD: CDAI (Crohn’s disease activity index)
The number of loose stools in the last 7 days
The strength of the abdominal pain: (0 point: no pain; 1 point: mild; 2 points: moderate; 3 points:
severe)/ day
General state (0 point: good; 1 point: appropriate; 2 points: weak; 3 points: bad; 4 points:
intolerable)/ day
Extraintestinal manifestations:
eye symptom: Yes / No
skin symptom: Yes / No
joint symptom: Yes / No
perianal fistula, fissura, abscess: Yes / No
internal fistula: Yes / No
fever (>37,8 C): Yes / No
Usage of obstipants (atropin, difenoxilát, loperamid or other): yes (1 point) /no (0 point)
Presence of Abdominal resistance: none (0 score) / questionable (2 points) /certain (5 points)
Deviation in hematokrit: males (47-htk)
females (42-htk) calculated value(if it is greater than normal, it is 0)
Deviation of the weight: 1-(actual weight/standard weight) (Below -10 count with -10)
CDAI score: ……………………….
<150 Inactive/remission
151-220 mild disease
221-300 moderate disease
301-450 severe disease
>450 very severe - fulminant
Activity of the Fistulazing CD: PDAI (perianal disease activity index):
Discharge: 0 point: - no discharge
1- point: minimal mucous discharge
2- points: Moderate mucous or purulent discharge
3- points: Substantial discharge
4- points: Gross fecal soiling
Pain/ restriction of activities: 0 point: no activity restriction
1- point: Mild discomfort, no restriction
2- point: Moderate discomfort, some limitation
activities
3- point: Marked discomfort, marked limitation
4- point: Severe pain, severe limitation
Restriction of sexual activity: 0 point- No restriction in sexual activity
1- point: Slight restriction in sexual activity
2- points: moderate restriction in sexual activity
3- points: marked restriction in sexual activity
4- points: Unable to engage in sexual activity
Type of the perianal disease: 0 point: no perianal disease/ skin tags
1 point: anal fissure or mucosal tear
2 points: <3 perianal fistulae
3 points: >3 perianal fistulae
4 points: Anal sphincter ulceration or fistulae with
significant undermining of skin
Degree of infiltration: 0 point: no induration
1 point: minimal induration
2 points: moderate induration
3 points: substantial induration
4 points: Gross fluctuance/abscess
PDAI score:……………
Physical examination of the abdomen:
Abdominal tenderness: Yes / No
If yes, please mark the localisation on the figure.
Muscular defense: Yes / No
Abdominal resistance: none/ questionable/certain
If yes, please mark the localisation on the figure.
Liver: normal / enlarged
Abnormalities:……………………..
Spleen: normal / enlarged
Rectal digital examination: normal / abnormal
Fistula: Yes / No
Abscess: Yes / No
Seton: Yes / No
Other physical abnormalities:
Lymph nodes: normal /abnormal
Mouth: aphta / soor / ulcer /normal
Other abnormalities: Yes / No
If yes, specify:…………………………
Description of the physical status:…………………………………………………
5.3. Serum tests
erythrocyte sedimentation rate (mm/h)
CRP (mg/l)
Blood WBC count (G/l) RBC count (T/l)
Hemoglobin (g/l)
Hematokrit (%)
MCV Platelet count (G/l)
Ions
Sodium (mmol/l) Potassium (mmol/l) Calcium (mmol/l) Magnesium (mmol/l)
Phosphate (mmol/l) Chloride (mmol/l) Iron (umol/l)
Pancreas
Glucose (mmol/l) Alfa amilase (U/l) Lipase (U/l)
Renal functions
Urea nitrogen (Karbamid) (mmol/l)
Kreatinin (umol/l)
eGFR
Liver functions Total bilirubin (umol/l)
Direct/conjugated bilirubin (umol/l) Indirect bilirubin (umol/l) ASAT/GOT (U/l) ALAT/GPT (U/l)
Gamma GT (U/l) Alkaline phosphatase (U/l)
Laktate dehydrogenase LDH (U/l)
Protrombin (%)
Protrombin INR
Metabolism
Cholesterol (mmol/l)
Triglicerides (mmol/l)
Uric acid (umol/l)
TSH (mU/l)l
HgbA1C (%)
Proteins
Total protein (g/l)
Albumin (g/l)
Globulin alfa1 (g/l)
Globulin alfa2 (g/l)
Globulin beta (g/l)
Globulin gamma (g/l)
Fibrinogen (g/l)
IBD
Procalcitonin (ng/ml)
IgA (g/l)
IgM (g/l)
IgG (g/l)
Ferritine (ug/l)
Transzferrin saturation (%)
B12 level (pmol/l)
Folic acid (nmol/l)
ASCA IgA
ASCA IgG
ANA
pANCA
IgG4 (g/l)
CEA (ug/l)
CA 19-9 (U/ml)
Infliximab TL (ug/ml)
Adalimumab TL (ug/ml)
Anti-drug antibody (ug/ml)
Anti-drug antibody (ug/ml)
Vvt.6-TGN (pmol/8x108 RBC)
Blood gases
PaO2 (Hgmm)
HCO3 (mmol/l)
sO2 (%)
Other
5.4. Suggestions
Is it possible to discharge the patient? Yes / No
If no, name the reason of hospital admission: severe disease activity / abscess /
perforation / other:…..
if yes,
Was dose modification needed at any of the currently taken drugs? Yes / No
if yes: dose elevation / dose reduction
Which drug’s dose was modified?...........................
New dose of the drug?................................
Was the discontinuation of a currently taken drug needed? Yes / No
If yes, the name of the drug:………..………..
The reason for discontinuing the drug: side effect / intolerance/ infusion reaction
/ Primary nonresponse / Secondary loss of response / financing reasons /
other:………………
Was the initiation of a completely new drug(s) needed? Yes / No
If yes, the name of the drug:………..……….. active
substance:………….……dose:………………... (gramm, milligramm, packet,
piece) how many times per day/ week.................................. way of intake:
…………………..(intravenous / per os / suppository/ enema)
Other comment:………………………………………
The reason for starting a new drug: disease activity / ineffectiveness of the
currently taken drug(s) / due to the patient’s complaints / intolerance of the
currently taken drug(s) / fistula formation
Will it be neccessary to perform any elective intervention in the next 12
months? Yes / No
If yes, what kind of intervention will be performed?
surgery / drainage / seton / endoscopic dilatation / upper endoscopy /lower
endoscopy
1. name and date of the intervention:…………………………………………
2. name and date of the intervention:…………………………………………
Will it be neccessary to perform any images in the next 12 months? Yes / No
If yes, what kind of images will be performed?
endoscopy / abdominal ultrasound / MRI / CT /Endoscopic ultrasound / ERCP
/MRCP
1. name and date of the image:…………………………………………
2. name and date of the image:…………………………………………