Understand It
Track It
Meet Fellow Crohnies
Lifestyle Tips
Treat It
Crohn's Happenings
Join Now
Join Now
Join now and get access to our video libraries and Crohn's Disease Tracker—only available to members.


Already part of the community?
Just enter your email address and password and you're in!
E-mail Address
Password
  Forgot your password?
Remember me
 

Want to join the community?
Fill out the information below, click submit, and you're a member!

*Denotes a required field

I am...*

First Name*
Last Name*
E-mail Address*
Create Password*
(At least 6 characters long)
Confirm Password*
Age*
Gender* Male Female
Phone ( ) - -
Want to hear
from us?
Yes, I am interested in receiving updates and news regarding Crohn's disease.
Via e-mail
 
Via US Mail
Address 1*
Address 2
City*
State*
Zip*
 

Overall, how would you describe your Crohn's disease?


Over the past six months, would you describe your Crohn's symptoms as high activity, low activity, or in remission? Roll over the question marks to read definitions.

Mid-High Activity
Low Activity
In Remission

Year of first CD diagnosis

When I learn about a different treatment for Crohn’s
that might help me, I:



Rate the following questions on a scale of 1 - 7.
1 = Completely disagree
4 = Neither agree nor disagree
7 = Completely Agree
I generally avoid taking prescription medicine to treat my Crohn’s disease.
1 2 3 4 5 6 7

I prefer to know about a lot of treatment options for my Crohn’s.
1 2 3 4 5 6 7

I generally wait for my doctor to suggest changes to my Crohn’s treatment.
1 2 3 4 5 6 7

Have you ever taken any of these medications?

  Current Med Former Med Never Taken
Aminosalicylates
Antibiotics
Corticosteroids
Immunomodulators
Biologic - Humira®
Biologic - Remicade®
Biologic - Tysabri®
 
 
Have you undergone surgery for CD?
Yes No
 

By submitting my information I agree that it will be
governed by this site's Privacy Policy and Terms of Use.

Humira is a registered trademark of Abbott Laboratories, Inc.
Remicade is a registered trademark of Centocor, Inc.
Tysabri is a registered trademark of Elan Pharmaceuticals, Inc.

 


Print this page