Pediatric | QuestionPro

What prescription medications are you currently taking?

How often do you see a dentist?

At least once per week

At least once per month

At least once every 3 months

Less than once every 3 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

Other

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?

Based on the last 7 days, do you have any of these extra-intestinal manifestations of Crohn’s disease (select all that apply):

Fever of 101°F or greater for 3 days over the past week

Definite arthritis

Uveitis (swelling or irritation of the eye)

Erythema nodosum (tender, red nodules under the skin)

Pyoderma grangrenosum (painful sores/ulcers on the skin)

For these last 3 questions, please answer using your worst day of the past 7 days:

Please rate your abdominal pain over the past 7 days:

None (no pain)

Mild (brief pain which does not interfere with activities and was present at least 2 out of the last 7 days)

Moderate/severe (daily pain, longer lasting, affects activities, and/or occurs at night)

How many stools have you had per day over the past 7 days?

0-1 liquid stools (diarrhea) per day with no blood

1-2 semi-formed stools with a small amount of blood, or 2-5 liquid stools per day

A lot of blood in your stool; or 6 or more liquid stools per day; or diarrhea during the night

General well-being:

Well (no limitation of activities)

Below par (occasional difficulty in maintaining regular activities)

Very poor (frequent limitation of activity)