Symptoms and Goals - Where you are now and where you want to be

Knowing whether or not your ulcerative colitis (UC) is well controlled is important. If your UC isn’t well controlled, you can talk to your doctor about treatment options and lifestyle modifications that may help you to achieve better control of your UC.

The following questions are intended to help you and your doctor make decisions about the ongoing management of your UC. During this 3-step process, you’ll answer questions about flares and your treatment experience (SYMPTOMS), and long-term goals for both UC control and your overall health (GOALS). When you are finished, you’ll be presented with a customized UC Action Plan that you can print and discuss with your doctor.

Please note that none of your information will be stored or used for any other purpose. Now, let’s get started!

SYMPTOMS: Where I Am Today

Select the option that best describes your answer to each of the 15 questions (be sure to answer all questions before moving down to the next section).

Q1-S: My ulcerative colitis has been diagnosed as:

Mild Moderate Severe Not Sure

Q2-S: I am currently experiencing a flare

Yes No

Q3-S: I typically experience flares

times a year

Q4-S: When I experience a flare, my symptoms usually include (check all that apply):

Bloody diarrhea  Rectal bleeding  Abdominal pain/cramping  Urgent need to go to the bathroom  Other

Q5-S: How many bowel movements per day do you experience with a typical flare? Enter a number in the field below.

Q6-S: How long do your flares tend to last?

Less than a week  weeks

Q7-S: I am currently taking a prescription medication for my ulcerative colitis:

True  False

Q8-S: Overall, how satisfied are you with your current UC medication(s)?:

Very satisfied  Somewhat satisfied  Not very satisfied  Not at all satisfied

Q9-S: When I do not take my medication as prescribed, it is for the following reason(s) (check all that apply):

I always take my medication as prescribed When I'm in remission I don't think about my UC as much It's not convenient-I have to take too many pills per day I have a hard time remembering to take all of my doses I don’t know how to take my medication I am concerned about the side effects

Q10-S: Thinking back to the last 12 months, how often has your UC interfered with work, school, social functions or other activities or responsibilities?

Not at all  Rarely  Fairly often  Quite often

Q11-S: Gaining better control of my ulcerative colitis will positively impact (check all that apply):

My relationship with my spouse My relationship with other family members My work Sexual relations My emotional state My general outlook on life

Now that you have answered some questions about your symptoms, it is time to answer some questions about your goals. Continue below: GOALS: Where I Want To Be Select the option that best describes your answer to each of the questions (be sure to answer all questions before clicking on the SUBMIT button)

Q12-G: I feel that my ulcerative colitis could be more controlled than it is

Yes No

Q13-G: According to the following scale, if your UC was more under control, do you feel your life would be:

Much less interrupted  Somewhat less interrupted  About the same  My life is not very interrupted now by my UC

Q14-G: If I joined a support program, I would want to receive (check all that apply):

Educational materials about UC Stories of other UC sufferers The latest treatment options Peer support information (phone number, blog info, chat boards…)

Q15-G: In addition to better ulcerative colitis management, I’d also like to work toward the following health goals:

Goal 1  Goal 2

Your personal answers to the assessment and goals survey will serve as a step towards helping you better manage your UC.

MY UC Action Plan - How I’m Going to Get There

Once you create your Action Plan you will receive:

• A print out of your responses that will help facilitate a discussion of your UC symptoms with your doctor
• A Symptom Tracker that can help you and your doctor track your symptoms and identify that there are patterns

Your UC Action Plan is intended to help you and your doctor work together to assess if your current treatment regimen is working for you. It will also help you track your personal UC management and health goals.

Now you’re ready to view your UC Action Plan – just click the button below to see your UC Action Plan PDF

	Clear Answers and start over

		Create Your UC Action Plan