Inflammatory Bowel Disease Symptom Assessment
Patient Name
Assessment Date
Diagnosis
Crohn's Disease
Ulcerative Colitis
Indeterminate Colitis
Bowel Movement Frequency (per day)
Stool Consistency
Formed
Loose
Watery
Bloody
Symptoms (check all that apply)
Abdominal Pain
Blood in Stool
Weight Loss
Fatigue
Fever
Extra-intestinal Manifestations
Current Medications
Additional Comments