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PCDAI: *see instructions on reverse re: scoring items marked * EXAMINATION HISTORY (Recall; 1 week)* Abdominal pain:* None Mild – Brief, does not interfere with activities Mod / severe - daily, longer lasting, affects activities, nocturnal _______(0) _______ (5) _______ (10) 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 _______ (0) _______ (5) _______ (10) 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 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 HCT (%) (values obtained within the past week) < 10 yrs : >33 28-32 < 28 ____ (0) ____ (2.5) ____ (5) >35 30-34 < 30 ____ (0) ____ (2-5) ____ (5) Males 15-19yrs: >37 32-36 < 32 ____ (0) ____ (2.5) ____ (5) Females 11-19yrs > 34 29-33 < 29 ____ (0) ____ (2.5) ____ (5) ESR (mm/hr) < 20 20-50 > 50 ____ (0) ____ (2.5) ____ (5) ALBUMIN (g/dL) > 3.5 ____ (0) 3.1-3.4 ____ (5) < 3.0 ____ (10) Males 11-14yrs _____ (0) _____ (5) _____ (10) _____ (0) _____ (5) _____ (10) OR ______ (0) _______ (5) _______ (10) _____ (0) _____ (5) _____ (10) Abdomen No tenderness, no mass Tenderness, or mass without tenderness Tenderness, involuntary guarding, definite mass _____ (0) _____ (5) _____ (10) Perirectal disease None, asymptomatic tags _____ (0) Inflamed tags or 1-2 indolent fistula(e) or fissure(s), scant drainage, no tenderness _____ (5) Active fistula, drainage, tenderness, or abscess _____ (10) Extra-intestinal Manifestations (Fever > 38.5 for 3 days over past week, oral ulcers definite arthritis, uveitis, E.nodosum, P. gangrenosum) None One > Two TOTAL SCORE _____ (0) _____ (5) _____ (10) _________________________________