Gastroenterology Behavioral Medicine Service: New Patient Questionnaire

BACKGROUND & PERSONAL DATA Name: Phone: EC Phone: Preferred contact method: Phone Email Marital Status: Occupation: Highest Level of Education Completed: Less than High School College Degree High School/GED Masters Degree Some College MD/PHD/JD Associates Degree Single Married/Life Partner Age: Email: Emergency Contact Name: Relationship to you: OK to leave a message? Divorced Separated Yes No

Widowed

# Years in Occupation:

CLINICAL INFORMATION Functional GI Disorder (e.g. IBS, FD, Globus, functional nausea, bloating) Inflammatory Bowel Disease (e.g. Ulcerative Colitis, Crohns, Proctitis) Eosinophilic Disorders (E. Esophogitis, E. Gastroenteritis) Celiac Sprue Other

What is your diagnosis type?

Please describe your symptoms: Current Medications: To what extent do you think stress impacts the course and/or treatment of your gastrointestinal condition? Does not impact the course or treatment of my condition Minimally impacts the course or treatment of my condition Moderately impacts the course or treatment of my condition Seriously impacts the course or treatment of my condition Are you currently taking any medications for your mental health (e.g. Prozac, Wellbutrin, Paxil, Zoloft, Seroquel, etc.)? Yes No If you are, please list them here: Name of the mental health professional you are currently seeing (if applicable):
Page 1 of 7

NUGI-BMed New Patient Intake Form 3.0, 2/18/2010

On a scale of 1 to 10, with 1 being mild and 10 being severe, please rate the severity of your GI symptoms during your most recent or current flare-up: 1 2 3 4 5 6 7 8 9 10 Good Fair Poor

Would you say that in general your health is:

Excellent

Very Good

Have you ever been bothered by any of the following issues (check as many that apply)? Work problems Relationship problems Difficulty with parenting Caregiver stress Difficulty managing stress Difficulties with communication Distrust of others Loss of interest in pleasurable activities Loss of independence Loss of a loved one Anxiety Obsessive thoughts or rituals Excessive worry Irritability Muscle tension Panic Attacks Fear of leaving the house Social anxiety Phobias Sleep disturbances Nightmares Fatigue Sexual dysfunction Chronic Pain Mood swings Depression Feeling sad or "blue" Thoughts of self-harm Low Self-Esteem Anger Excessive guilt Loneliness Trauma Abuse (physical, sexual, emotional) An eating disorder (i.e. anorexia nervosa, bulimia, binge eating) Problems with Addiction (drugs, gambling, internet, alcohol, sex)

OTHER MEDICAL DIAGNOSES & TREATMENTS Please list other medical and/or psychiatric conditions that you have here Approximate Date of Diagnosis / / May we discuss the relevant/important aspects of your care with your MD? Yes / / No No No

Are you interested in completing additional questionnaires relevant to your condition? Yes May we use this information for research purposes in the future? Yes

Patient Signature
Page 2 of 7

Date
NUGI-BMed New Patient Intake Form 3.0, 2/18/2010

QOL Questionnaire Please think about your life over the past month (30 days) and look at the statements below. Each statement has five responses. For each statement, please circle the response that best describes your feelings. During the past month 1. I feel helpless because of my bowel problems. 2. I am embarrassed by the smell caused by my bowel problems. 3. I am bothered by how much time I spend on the toilet. 4. I feel vulnerable to other illnesses because of my bowel problems. 5. I feel fat because of my bowel problems. 6. I feel like Im losing control of my life because of my bowel problems. 7. I feel like my life is less enjoyable because of my bowel problems. 8. I feel uncomfortable when I talk about my bowel problems. 9. I feel depressed about my bowel problems. 10. I feel isolated from others because of my bowel problems. 11. I have to watch the amount of food I eat because of my bowel problems. 12. Because of my bowel problems, sexual activity is difficult for me. 13. I feel angry that I have bowel problems. 14. I feel like I irritate others because of my bowel problems. 15. I worry that my bowel problems will get worse. 16. I feel irritable because of my bowel problems. 17. I worry that people think I exaggerate my bowel problems. 18. I feel I get less done because of my bowel problems. 19. I have to avoid stressful situations because of my bowel problems. 20. My bowel problems reduce my sexual desire. 21. My bowel problems limit what I can wear. Not at All 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Slightly 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
Page 3 of 7

Moderately 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

Quite a bit 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

Extremely 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

NUGI-BMed New Patient Intake Form 3.0, 2/18/2010

During the past month 22. I have to avoid strenuous activity because of my bowel problems. 23. I have to watch the kind of food I eat because of my bowel problems. 24. Because of my bowel problems, I have difficulty being around people I do not know well. 25. I feel sluggish because of my bowel problems. 26. I feel unclean because of my bowel problems. 27. Long trips are difficult for me because of my bowel problems. 28. I feel frustrated I cannot eat what I want because of my bowel problems. 29. It is important to be near a toilet because of my bowel problems. 30. My life revolves around my bowel problems. 31. I worry about losing control of my bowels. 32. I fear that I wont be able to have a bowel movement. 33. My bowel problems are affecting my closest friends. 34. I feel that no one understands my bowel problems.

Not at All 1 1 1

Slightly 2 2 2

Moderately 3 3 3

Quite a bit 4 4 4

Extremely 5 5 5

1 1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3 3

4 4 4 4 4 4 4 4 4 4

5 5 5 5 5 5 5 5 5 5

Page 4 of 7

NUGI-BMed New Patient Intake Form 3.0, 2/18/2010

BSI 18 is a registered trademark of Leonard R. Derogatis, Ph.D

Brief Symptom Inventory

Below is a list of problems people sometimes have. Please read each one carefully and blacken the circle that best describes HOW MUCH THAT PROBLEM HAS DISTRESSED OR BOTHERED YOU DURING THE PAST 7 DAYS INCLUDING TODAY. Blacken the circle for only one number for each problem and do not skip any items.
HOW MUCH WERE YOU DISTRESSED BY:
Not At All A Little Bit Moderately Quite A Bit Extremely

1. Faintness or dizziness . . . . . . . . . . . . . . . . . . . . . . . . 2. Feeling no interest in things . . . . . . . . . . . . . . . . . . . 3. Nervousness or shakiness inside . . . . . . . . . . . . . . . 4. Pains in heart or chest . . . . . . . . . . . . . . . . . . . . . . . 5. Feeling lonely . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. Feeling tense or keyed up . . . . . . . . . . . . . . . . . . . . . 7. Nausea or upset stomach . . . . . . . . . . . . . . . . . . . . . 8. Feeling blue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9. Suddenly scared for no reason . . . . . . . . . . . . . . . . . 10. Trouble getting your breath . . . . . . . . . . . . . . . . . . . 11. Feelings of worthlessness . . . . . . . . . . . . . . . . . . . . 12. Spells of terror or panic . . . . . . . . . . . . . . . . . . . . . 13. Numbness or tingling in parts of your body . . . . . 14. Feeling hopeless about the future . . . . . . . . . . . . . . 15. Feeling so restless you couldnt sit still . . . . . . . . . 16. Feeling weak in parts of your body . . . . . . . . . . . . . 17. Feeling fearful . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18. Thoughts of ending your life. . . . . . . . . . . . . . . . . . .

Adapted or reproduced from the Brief Symptom Inventory 18. Copyright 2000 Leonard R. Derogatis, Ph.D., this adaptation 2001. Published and distributed exclusively by NCS Pearson, Inc. Licensed through NCS Pearson, Inc. Page 5 of 7

NUGI-BMed New Patient Intake Form 3.0, 2/18/2010

Brief COPE* for Bowel Disease (BCBD) The following items deal with ways you may be with the bowel-related distress. There are many ways to try to deal with problems. These items ask what youve been doing to cope. Obviously, different people deal with things in different ways, but were interested in how youve tried to deal with things in your life. Each item says something about a particular way of coping. I want to know to what extent youve been doing what the item suggests. Dont answer on the basis of whether it seems to be working or not just whether or not youre doing it. Use the response choices below. Try to rate each item separately in your mind from the others. Make your answers as true for you as you can. 0 = not at all 1 = some of the time 2 = most of the time 3 = a lot or all of the time 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

Ive been turning to work or other activities to take my mind off my intestinal problems. Ive been concentrating my effort on doing something about the situation Im in. Ive been saying to myself, this isnt real. Ive been using alcohol or other drugs to make myself feel better. Ive been getting emotional support from others. Ive been giving up trying to deal with my intestinal problems. Ive been taking action to try to make the situation better. Ive been refusing to believe that this is happening to me. Ive been saying things to let my unpleasant feelings escape. Ive been getting help and advice from other people. Ive been using alcohol or other drugs to help me get by. Ive been trying to see things in a different light, to make it seem more positive. Ive been criticizing myself. Ive been trying to come up with a strategy about what to do about my intestinal problems. Ive been getting comfort and understanding from someone. Ive been giving up the attempt to cope with my intestinal problems. Ive been looking for something good in what is happening. Ive been using humor to deal issues in my life including my bowel habits. Ive been doing something to think about my situation less, such as going to movies, watching television, reading, daydreaming, sleeping, or shopping. Ive been accepting the reality of the fact that I have intestinal problems. Ive been expressing my negative feelings. Ive been trying to find comfort in my religion or spiritual beliefs. Ive been trying to get advice or help from other people about what to do. Ive been learning to live with my intestinal problems. Ive been thinking hard about what steps to take to manage my intestinal problems. Ive been blaming myself for things that happened in the past. Ive been praying or meditating. Ive been making fun of the situation.
Page 6 of 7

0 0 0 0 0 0 0 0 0

1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3

NUGI-BMed New Patient Intake Form 3.0, 2/18/2010

If you are here to see us for bowel problems, please respond to the following questions as openly and honestly as you can.
1.

a) Do you currently (in the last month) suffer from abdominal (tummy) pain?

no yes

b) If yes, how severe is your abdominal (tummy) pain? Please indicate a number from 0 to 100, with 0 meaning no pain and 100 meaning very severe c) Please enter the number of times that you get the pain every 10 days. For example, if you enter 4 it means that you get pain 4 out of 10 days. If you get pain every day enter 10. Number of days with pain:

2.

a) Do you currently suffer from abdominal distention * (bloating, swollen or tight tummy)

no yes

*Women, please ignore distention related to your period b) If yes, how severe is your abdominal distention/tightness? Please indicate a number from 0 to 100, with 0 meaning no distention and 100 meaning very severe
3.

How dissatisfied are you with your bowel habits? Please indicate a number from 0 to 100, with 0 meaning very happy and 100 meaning very unhappy

4.

Please indicate how much abdominal pain or discomfort or altered bowel habits are affecting or interfering with your life in general. Please indicate a number from 0 to 100, with 0 meaning not at all and 100 meaning completely

Page 7 of 7

NUGI-BMed New Patient Intake Form 3.0, 2/18/2010