History (Recall; 1 week)
Abdominal pain:
None 
Mild-- Brief, does not interfere with activities
Mod/severe - daily, longer lasting affects activities, nocturnal
Stools (per day):
Formed stools or up to 1 liquid stool, no blood
Up to 2 semi-formed with small blood, or 2-5 liquid with or without small blood
Any gross bleeding, or ≥ 6 liquid, or nocturnal diarrhea
Patient Functioning -- General Well-Being
No Limitation of activities, well
Occasional difficulty in maintaining appropriate activities, below par
Frequent limitation of activity, very poor
Laboratory (values obtained within the past week)
Sex:  Age(whole years):  Hematocrit %:  ESR (mm/hr): Albumin (g/dl): 
Examination
Weight
Weight gain or voluntary weight stable/loss
Involuntary weight stable, weight loss 1-9%
Weight loss ≥ 10%
Height: Score using (a) criteria when possible
(a)
 Height velocity ≥—1SD
Height velocity <—1SD, >—2SD
Height velocity ≤—2SD
(b) <1 channel decrease
≥1,<2 channel decrease
>2 channel decrease
Abdomen
No tenderness, no mass
Tenderness, or mass without tenderness
Tenderness, involuntary guarding, definite mass
Perirectal disease
None, asymptomatic tags
Inflamed tags or 1-2 indolent fistula(e) or fissure(s), scant drainage, no tenderness
Active fistula, drainage, tenderness, or abscess
Extra-intestinal Manifestations
(Fever≥38.5°C for 3 days over past week, oral ulcers, definte arthritis, uveitis, erythema nodosum, pyoderma gangrenosum) None
One
≥ Two
Final Score
Total Score: