Inflammatory Bowel Disease (IBD) and Diet - Patient Questionnaire 
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What is your age?
What is your gender?
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What is your height in centimetres?
What is your weight in kilograms?

Can you identify your type of IBD?

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How many years have you had IBD?
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At what age were you when your IBD was diagnosed?

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What is the location of your IBD?

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Have you experienced any of the following complications of Crohn's Disease?

Since your diagnosis, what has happened to your weight? (i.e., compare your weight now to your weight at diagnosis)

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Do you believe any change in your weight is due to your IBD? (On a scale from 1-5)

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Do you feel that your weight contributes to the severity of your IBD? (On a scale from 1-5)

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How do you feel about your weight at the moment?

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How important is diet for your IBD? 

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If you believe that diet affects your IBD, what role do you believe it has?

Do you believe that your gastroenterologist/IBD specialist places importance on the role of diet?                
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Have you received steroids in the past year? (Steroids include medicines like prednisolone and hydrocortisone)

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How many courses of steroids have you received in the past?

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Are you treated with Azathioprine, Mercaptopurine, Mesalazine or Methotrexate? 

You may choose more than one option

Are you treated with a biologic or small molecule medication? (Medication that ends in -mab or -nib, e.g. infliximab)

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Have you had surgery for IBD?

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If you have had surgery, please describe your understanding of the extent of bowel removed

Do you take any dietary supplements or vitamins, and if so, which do you take?

Are there particular foods that you avoid?

What do you think of your diet?

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How often do you see your gastroenterologist/IBD specialist?

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Has your specialist given you dietary advice, or referred you to a dietitian? (you may select more than one option)

Has your general practitioner given you dietary advice, or referred you to a dietitian? (you may select more than one option)

Have you seen a dietitian?

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Have you received dietary advice from another health practitioner?

Have you been referred to any online dietary resources by a health practitioner? And if so, which?

Have you followed dietary advice given to you by any of these health practitioners?

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If you have followed advice, what advice have you followed - and why?

Was there advice you did not follow? What was that, and why did you not follow it?

Have you sought out online diet information? If so, from where?       

From which of the following do you have some knowledge or personal experience?

If you have followed one of the above dietary modifications, please describe which, and whether you found it useful (on a scale from 1-5 for each diet, 1 being not effective at all, and 5 being very effective).

Were you satisfied with your dietary advice?                  
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Do you use dietary modifications to control your symptoms? If yes, please describe which. 

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