Community IBD Screening Questionnaire

In the past 3 months, have you experienced:

Frequent abdominal pain or cramping (more than once a week)?Persistent diarrhea (lasting more than 1 week)?Blood or mucus in the stool?Unexplained weight loss?Urgency to have a bowel movement?Feeling of incomplete evacuation after bowel movement?Fatigue or low energy levels?Fever not related to other known illnesses?

1. Have you been diagnosed with any bowel disorder previously?

YesNo

2. Do you have a family history of IBD (Crohn’s disease or ulcerative colitis)?

YesNo

3. Have you ever been hospitalized for gastrointestinal issues?

YesNo

1. Have you had symptoms for more than 6 weeks?

YesNo

2. Are your symptoms affecting your daily activities or quality of life?

YesNo

1. Do you smoke?

YesNo

2. Do you consume alcohol regularly?

YesNo

3. Do you follow any specific diet? (e.g., gluten-free, vegetarian)

YesNo

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