TABLE 2.

Symptoms and Impacts Questionnaire for Crohn's Disease (SIQ‐CD)

Daily Bowel Movement Report 1. When did you have this bowel movement? – Just now – Earlier today (please enter time) 2. How strong was your urge to use the restroom before this bowel movement? – Not strong at all – Mild – Moderate – Very strong – Extremely strong 3. Were you able to reach the toilet in time with this bowel movement? – Yes, I made it to the toilet on time – No, I had an accident before reaching the toilet 4. How severe was your rectal bleeding with this bowel movement? – No bleeding at all – Mild – Moderate – Severe – Very severe 5. Please select the picture and description that best resembles your stool. Daily Symptom Diary 1. How severe was your worst abdominal cramping during the last 24 hours? – No cramping at all – Mild – Moderate – Severe – Very severe 2. How severe was your worst abdominal pain during the last 24 hours? – No pain at all – Mild – Moderate – Severe – Very severe 3. How severe was your worst joint pain during the last 24 hours? – No pain at all – Mild – Moderate – Severe – Very severe 4. How would you rate your worst feelings of tiredness during the last 24 hours? – No tiredness at all – Mild – Moderate – Severe – Very severe 5. How often did you experience low energy during the last 24 hours? – Never – Rarely – Sometimes – Often – Always 6. How often did you feel weak in the last 24 hours? – Never – Rarely – Sometimes – Often – Always 7. How often did you have a poor appetite during the last 24 hours? – Never – Rarely – Sometimes – Often – Always 8. How often did you experience nausea during the last 24 hours? – Never – Rarely – Sometimes – Often – Always 9. How many times did you vomit during the last 24 hours (enter number of times)? Weekly Impact Assessment 1. Over the last 7 days, how limited were you in the types of food you could eat because of your Crohn's disease? – Not limited at all – A little limited – Moderately limited – Very limited – Extremely limited 2. Over the last 7 days, how limited were you in the amount of food you could comfortably eat because of your Crohn's disease? – Not limited at all – A little limited – Moderately limited – Very limited – Extremely limited 3. Over the last 7 days, how limited were your activities because of the need to be near a restroom? – Not limited at all – A little limited – Moderately limited – Very limited – Extremely limited 4. Over the past 7 days, how limited were your social activities because of your Crohn's disease? – Not limited at all – A little limited – Moderately limited – Very limited – Extremely limited 5. Over the past 7 days, how limited were your leisure activities because of your Crohn's disease? – Not limited at all – A little limited – Moderately limited – Very limited – Extremely limited 6. Over the past 7 days, how limited was your overall functioning because of your Crohn's disease? – Not limited at all – A little limited – Moderately limited – Very limited – Extremely limited 7. Over the past 7 days, how difficult was it for you to complete your responsibilities at work or school because of your Crohn's disease? – Not difficult at all – A little difficult – Moderately difficult – Very difficult – Extremely difficult – Not applicable: I did not work or attend school in the past 7 days because of my Crohn's disease – Not applicable: I did not work or attend school in the past 7 days for reasons not related to my Crohn's disease 8. Over the past 7 days, how difficult was it to complete housework or chores because of your Crohn's disease? – Not difficult at all – A little difficult – Moderately difficult – Very difficult – Extremely difficult 9. Over the past 7 days, how difficult was it to complete your family responsibilities because of your Crohn's disease? – Not difficult at all – A little difficult – Moderately difficult – Very difficult – Extremely difficult – Not applicable: my Crohn's disease has made me unable to have children or has influenced my choice not to have children – Not applicable: I do not have children or others who depend on me, for reasons not related to my Crohn's disease 10. Over the past 7 days, how limited were you in physical activities because of your Crohn's disease? – Not limited at all – A little limited – Moderately limited – Very limited – Extremely limited 11. Over the past 7 days, how difficult were relationships with friends because of your Crohn's disease? – Not limited at all – A little limited – Moderately limited – Very limited – Extremely limited 12. Over the past 7 days, how difficult were relationships with family because of your Crohn's disease? – Not difficult at all – A little difficult – Moderately difficult – Very difficult – Extremely difficult 13. Over the past 7 days, how limited were your sexual activities because of your Crohn's disease? – Not limited at all – A little limited – Moderately limited – Very limited – Extremely limited – Not applicable: I did not attempt sexual activities in the past 7 days because of my Crohn's disease – Not applicable: I did not attempt sexual activities in the past 7 days for reasons not related to my Crohn's disease 14. Over the past 7 days, how much has Crohn's disease interfered with your quality of life? – Not at all – A little bit – Moderately – Very much – Extremely 15. Over the past 7 days, how often have you worried about having an accident related to your Crohn's disease? – Never – Rarely – Sometimes – Often – Always 16. Over the past 7 days, how often has your Crohn's disease caused you to feel embarrassed? – Never – Rarely – Sometimes – Often – Always 17. Over the past 7 days, how often has your Crohn's disease caused you to feel sad? – Never – Rarely – Sometimes – Often – Always