Adults | QuestionPro

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?

Have you felt that your sense of taste has worsened because of problems with your teeth, mouth or dentures?

Have you had painful aching in your mouth?

Have you found it uncomfortable to eat any foods because of problems with your teeth, mouth or dentures?

Have you been self-conscious because of your teeth, mouth or dentures?

Have you felt tense because of problems with your teeth, mouth or dentures?

Has your diet been unsatisfactory because of problems with your teeth, mouth or dentures?

Have you had to interrupt meals because of problems with your teeth, mouth or dentures?

Have you found it difficult to relax because of problems with your teeth, mouth or dentures?

Have you been a bit embarrassed because of problems with your teeth, mouth or dentures?

Have you been irritable with other people because of problems with your teeth, mouth or dentures?

Have you had difficulty doing your usual jobs because of problems with your teeth, mouth or dentures?

Have you felt that life in general was less satisfying because of problems with your teeth, mouth or dentures?

Have you been totally unable to function because of a problem with your teeth, mouth or dentures?

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