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1. Demographic Details

Sex *
0 / 35
Place of Residence *
Occupation of the Head *
Education of the Head of the family *
Total monthly income of the family (2021) *

2. Personal Medical History

Compliance to treatment *

3. Family History

4. Environmental Factors

Mode of Delivery *
Place of Birth *
Who Conducted Delivery? *
Gurti/Prelacteal feed *
Breast Feed *
If Yes, Duration of breastfeed *
Formula feed along with breast feed *
If Yes, age of introduction of formula feed *
Vaccination Status (prefer to see vaccination card) (look for BCG, HBV, OPV, MMR, DPT) *
Hospitalization in first month of life *
Hospitalization in first 2 years of life *
Hospitalization between 2-5 years of age *
Number of antibiotic courses before the age of 5 years *
Did you receive intravenous antibiotics in first 5 years of life? *
Surgery before the age of 5 years *
Specify *
Infections before the age of 5 years *
Number of infectious episodes till 5 years of age *
Average time spent per day on mobile phone? (hours) *
Type of House *
Number of family members living in same house(Age more than 18 Years) *
Number of family members living in same house(Age Between 12 and 18 Years) *
Number of family members living in same house(Age less than 12 Years) *
Number of Rooms in House *
Toilet facility in house *
Sewerage system available *
Source of Drinking Water *
Do you purify/treat water before drinking? *
If Yes, what method? *
Refrigerator in house *
Garbage disposal *
Job Profile *
If agriculturist, what is your work mode
Does your occupation require travel outside hometown? *
Frequency of travel *
Do you take outside meals during your travel for work? *
Exposure to Pets *
Specify *
Stressful Events (In Past 2 years) *
Outdoor Physical Activity (Walking, Jogging, Running, Cycling, Swimming, etc.) *
Frequency *
Time Spent on Physical Activities per week *
Sleep *
Sleep Quality *
Dietary Habits *
Do you drink alcohol? *
Do you smoke? This includes if you smoke cigarette, biddis, or hukka. *
Have you ever used illicit injectable drugs during your lifetime? We consider these to be any drugs, including prescription drugs or street drugs that are injected for recreational use and not for a specific medical purpose prescribed by a doctor. *
Do you share needles, syringes, or other injection equipment with other drug users? *
Have you ever used Bhukki / Afeem / Doda? *
Have you ever eaten or consumed Paan or Paan Masala or Gutkha? *
In the past one year, did you use PPIs? *
In the past one year, did you use NSAIDs/Pain Killers? *
In the past one year, did you use antibiotics? *
In the past one year, did you use Alternative Medicines? *
In the past one year, did you use steroids? *

5. Clinical symptoms suggestive of IBD

Failure to gain weight *
Failure to gain height *
Diarrhoea *
Duration *
Blood in stools *
Duration *
Abdominal distension *
Duration *
Vomiting *
Duration *
Nocturnal diarrhoea *
Duration *
Fever *
Duration *
Pain abdomen *
Duration *
Fatigue *
Duration *
Weight loss *
Duration *
Loss of appetite *
Duration *

6. Extra intestinal manifestations

Arthritis (Peripheral)) *
Duration *
Arthritis (Axial) *
Duration *
Arthralgias *
Duration *
Erythema Nodosum *
Duration *
Gall Stones *
Duration *
Episcleritis/Scleritis/Uveitis *
Duration *
Pyoderma Gangrenosum *
Duration *
Anemia *
Duration *
DVT *
Duration *

7. Investigations

Finding Suggestive of
Extent
Endo Mayo
Location
Behaviour

8. Habitual Diet

Wheat (Chapati, Roti, Naan, Dalia, Rawa/Sooji, Vermicelli/Seviyaan, etc) *
Maize (Chapati, Chhalli, Bhutta, Corn Cob, etc) *
Oats (Oat meal, Rolled Oats) *
Barley *
Ragi/Bajra/Jowar *
Amaranth (Chulai/Rajgira/Seel) *
Rice *
Red / Deep Orange / Yellow Fruits (Mango, Papaya, Peach, Musk Melon, Watermelon, Apricot) *
Citrus Fruits (Lemon, Orange, Grapefruit, Sweetlime) *
Berries and Grapes (Raspberry, Cherry, Strawberry, Cranberry, Blackberry, Gooseberry/Amla, Grapes) *
Others (Apple, Banana, Pear, Pomegrenate, Custard Apple/Sitafal, Cheeku/Sapota, Plum, Kiwi, Litchi, Jackfruit/Kathal, Dates, Fig, etc) *
Green Leafy (Spinach, Mustard/Sarson, Bathua, Fenugreek, Lettuce, Other Leafy Greens) *
Green (Gourds (Ghia, Tinda, Tori, Kaddu/Pumpkin, Bitter gourd/Karela, etc.) Capsicum, Green Beans, Lady finger) *
Cruciferous (Cauliflower, Broccoli, Cabbage) *
Starchy (Potato, Sweet potato, Yam/Kalakand, Tapioca/Kachalu, Arbi/Colocasia) *
Bulbs (Garlic/Onion) *
Others (Brinjal, Turnip, Carrot, Radish, Cucumber, Tar/Kakdi, Ginger, Mint, Coriander) *
Pulses (Lentils, Arhar, Tur, Green gram (moong), Black gram (urad), Masur, Bengal Gram (kale chane), etc.) *
Legumes (Green Peas, Chickpea (Kabuli Chana), Kidney bean (rajmah), Lobia/Rongi, etc.) *
Soybeans *
Desi Ghee/Butter/Malai *
Coconut Oil/Palm Oil *
(Rice Bran Oil, Sunflower oil, Safflower/Kusam oil, Soybean oil, Cottonseed oil, Corn oil, Groundnut oil, Gingelly/Sesame/Til Oil, Canola Oil etc.) *
(Linseed oil (Alsi), Canola Oil, Mustard Oil, Olive Oil) *
Dalda/Vanaspati, etc. *
Almonds, Walnuts, Groundnuts, Cashewnuts, Pistachio, Pine Nuts, Chia Seeds, Flax Seeds, Garden Cress Seeds, Sesame Seeds/Til, Pumpkin Seeds, Sunflower Seeds, Coconut Kernel *
Eggs *
Chicken / Turkey *
Red Meat (Mutton/ Pork/ Beef) *
Fish and Seafood *
Milk *
Homemade Curd *
Homemade Buttermilk / Lassi / Chaach *
Paneer (Cottage Cheese) *
Khoya *
Carbonated Drinks/ Soda *
Bottled /Tetra-pack /Powdered Juices / Fruit Drink / Concentrates *
Energy Drinks (Gatorade /Red Bull / Others) *
Bottled / Packed Dairy Drinks (Flavoured Milk, Lassi, Buttermilk, Chhaach, Dahi/Curd, Flavored Yogurts, Coffee, Teas) *
Packed Breads/Buns/Kulcha/Pav *
Cakes / Muffins / Pastry / Cake Mix *
Breakfast Cereal/Breakfast Bars *
Ice Cream *
Puddings and Pies *
Jellies n Jams *
Chocolates *
Dressings, Mayonnaise, Spreads and Margarines *
Candies/Gummies *
Packed Soups *
Instant Noodles *
Packaged Meat/Fish/Vegetables *
Processed Cheese *
Condensed Milk/Milkmaid *
Pre Prepared Ready To Eat Meals *
Salty (Chips/Kurkure/Cookies/ Biscuits/Tortillas) *
Sweet (Biscuits/ Rusks/ Cookies) *
Samosa/ Kachori/ Mathi/Matri/ Murruku/ Chakli/Chidwa/ Pakora/ Fritters/ Mirch Bhaji/ Vada Pav/ Batata Vada/ Aloo Bonda/ Vada/ Medu Vada/ Tikki/Papdi Chaat/ Bhatura/ etc. *
Manchurian/Burger/Hot Dogs/Fries/……….. *
Bhel Puri/ Muri/ Pani Puri/ Puchka/ Vermicelli/ Dahi Bhalla/Dhokla/Khakhra/Fafra/etc. *
Pizza/Pasta/Noodles/Chowmein/ Patty/Puff/Momos/………… *
Frozen Food (Vegetables, Fruits, Meals, Fish, Meat, Corn) *
Ketchup / Puree *
Pickles *
Chutney *
Canned Vegetables Preserved in Salty Solutions/Vinegar *
Canned Fruits in Sugar Syrup *
Canned Fish *
Salted Dried Smoked Meat/Fish/ Sausages *
Khoya Burfi/ Kalaland / Gulab Jamun/ Kheer/ Rabri/ Khurchan/ Jalebi/ Imarti/ Halwa/ Sheera/ Laddoo/ Atta, Besan, Dal – Pinni or Barfi/ Panjiri/ Choorma, Rasgulla, Chhena Murgi/ Sandesh/ Khurmani Ka Meetha/ Ande Ka Meetha/ etc.
Calcium supplements *
Vitamin D Supplements *
Zinc Supplements *
Iron Supplements *
Protein Supplements *
Fat Burners / Body Building Gym Supplements *
Multivitamins Supplements *
Almond Milk/ Coconut Milk/ Soy Milk/ Oat Milk/ Tofu *

9. Dietary Patterns and Practices

How many major meals do you take in a day? *
Do you have fixed meal hours? *
Do you skip your meals? *
What is the usual time for dinner? *
Do you take salad with your major meals? *
Do you sprinkle (added) salt on your salad/ fruits/vegetables/ dal etc.? *
Is your food spicy for your friends/colleagues? *
What drink do you have with meals? *
Which flour do you prefer to use? *
Do you sieve the atta before making dough for chapati? *
How often do you use commercially available batters for foods like idli, etc? *
How many times do you cook fresh food in a day? *
How often do you consume ‘left over foods’ after refrigeration? *
How do you re-heat refrigerated food? *
What is your preferred way of cooking vegetables/curries? *
Do you temper (tadka) your dal/vegetables everytime? *
What is the source of regular milk that you usually use? *
What is the form of sugar that you use? *
How frequently do you eat out/order food from outside? *
How many cups of tea do you drink in a day? *
How many cups of coffee do you drink in a day? *
How many cups of milk do you drink in a day? *
How many teaspoons of sugar do you add to a cup of milk/tea/coffee? *
How do you wash fruits and vegetables before consuming? *
Do you have your fruit with peel? *
What is your preferred / most frequently eaten /ordered food from outside? *
How do you use oil left after frying? *
What are the common spices used in your cooked food /tadka ? *
Do you take PPIs routinely?
Do you take NSAIDs routinely? *
Do you take antibiotics routinely? *
Do you have any known food allergy?
How do you purify water at home? *

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