The diet of paediatric IBD patients
1
About You
If you are under 16 years you should complete this survey with support of a parent or guardian. Please tell us who is completing this survey:
Patient (older than 16 years)
Patient and parent/guardian together
Parent/guardian without patient
Have you had a diagnosis of IBD by a hospital consultant?
Yes
No
What type of IBD do you have?
Crohn's disease
Ulcerative colitis
Microscopic colitis
Indeterminate colitis
Do you take any regular treatment for your IBD? If yes, please specify what and how frequently
What is your current age in years (age of patient)?
How long has it been since your original diagnosis (in years)?
What sex are you (sex of patient)?
Male
Female
Where do you live (enter the first part of your postcode e.g. BN1 or BN43)?
What would you consider your current disease activity to be?
In flare
Some symptoms but not flaring
Symptom free
Clinical remission
How well controlled has your IBD been over the past 12 months?
Completely well, no flare-ups
Only 1 flare-up
2-3 flare-ups
4-6 flare-ups
Greater than 6 flare-ups
Do you think in between your flare-ups you feel completely well. If NO; specify what symptoms you experience
Have you had any surgery for your IBD since diagnosis?
Yes
No
Of what ethnic origin do you consider yourself to be?
White - English/Welsh/Scottish/Northern Irish/British
White - Irish
White - Gypsy or Irish Traveller
White - Any other white background
White and Black Caribbean
White and Black African
White and Asian
Any other mixed/multiple ethnic background
Asian - Indian
Asian - Pakistani
Asian - Bangladeshi
Asian - Chinese
Asian - Any other Asian background
Black - African
Black - Caribbean
Black - Any other black/African/Caribbean background
Arab
Another ethic group
Prefer not to say
Next
2
Your Diet
3
Thank You
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