crohn header1 crohn header2 crohn header 3 crohn header 4
Home irishhealth.com Clinics crohns header 5header 5_2
search irishhealth blue blue gradient crohn header 9header 7_1
 
Search Now
pink top
     Newly diagnosed
line
     Basics
line
     Living with Crohn's
     Disease
line
     Take Control
line
     Advanced Resources
line
     News Channel
line
     About the ISCC
line
     Questionnaire
line
     Medical Q&As
 
pink base

Stay informed of site updates:
 
  crohn header 8 header 8_2
Questionnaire
crohn header 9
 header 9 1


Required fields are indicated with a *
* Sex: Male Female
* First name:
Surname:
Email address:
Confirm email address:
* Year of birth:
* Year when first diagnosed:
* Please rate, on a scale of 1 to 5 how well you feel you are coping with your condition right now (1= very poorly; 5= very well)
12345
* Please rate, on a scale of 1 to 5, overall how well you feel you've coped with your condition over the last year (1= very poorly; 5= very well)
12345
* What aspect(s) of your condition would you like more information on? (tick as many as apply)
a. Coping at Work
b. Travelling
c. Support Groups
d. Managing Diets
e. Weight Issues
f. Remembering Medications
g.    Other (please state)
Tick this box if you would like to be informed of special services from this website to help you manage your condition
Tick this box if you would you like to find out more about the Irish Society for Colitis and Crohn's Disease
* How did you find out about the Crohn's Clinic

Search Engine eg. Google
My Doctor/Nurse
Friend/Colleague
Media
 

line
Copyright © 2007. All rights reserved. We subscribe to the principles of the Health On the Net Foundation
Clinic supported by an unrestricted educational grant from Abbott