MY IBD PASSPORT. Helping to keep me on track

Transcription

1 MY IBD PASSPORT Helping to keep me on track

2 This health passport belongs to: Name: Address: Home phone: Other phone: Emergency contact: Phone: Other phone: In this health passport, you will be able to enter important health information related to your inflammatory bowel disease (IBD). It will help you keep track of your tests, medications, vaccinations, surgeries and more. So make sure you bring it to all your appointments, especially when you visit a new health care professional. This health passport is meant as a notebook. Don t hesitate to ask your doctor if you have questions or would like more information.

3 My health care team Gastroenterologist: Clinic/Office address: Phone: Fax: IBD Nurse: Clinic/Office address: Phone: Fax: Secretary: Phone: Fax: Gastrointestinal or inflammatory bowel disease nurse.

4 Family physician: Clinic/Office address: Phone: Fax: Pharmacy: Address: Phone: Fax:

5 My health care team Nutritionist: Clinic/Office address: Phone: Fax: Stomotherapist: Phone: Fax: Other specialist: Clinic/Office address: Phone: Fax:

6 My medical profile My treatment goal

7 My medical profile Disease diagnosis Crohn s disease Date of diagnosis: At diagnosis Ulcerative Colitis Date of diagnosis: Indeterminate Colitis Date of diagnosis: Other (specify): Date of diagnosis: Location of disease Shade in the location of your disease at diagnosis and now. Perianal involvement: Abscess Skin tags Fissure Fistulae

8 Now (Date: )

9 My medical profile Allergies or food intolerance

10 Other significant medical conditions List any other medical conditions you had at diagnosis. Mouth Mouth sores Skin Erythema nodosum Pyoderma gangrenosum Psoriasis Joints Swollen joints Ankylosing spondylitis Liver Primary sclerosing Autoimmune hepatitis cholangitis (PSC) Eyes Iritis Uveitis Cataract Cancer (specify): Other (specify):

11 My medical profile Surgeries Shade in the portions of your digestive tract that were removed and include the dates of your surgeries. Other previous surgical procedures (specify):

12 Physical changes Date: Weight: Height: Date: Weight: Height: Date: Weight: Height: Date: Weight: Height: Date: Weight: Height: Date: Weight: Height: If you would like to know more about monitoring and assessing children s growth, visit for Canadian adaptations of the World Health Organization growth charts. Smoker Yes No If yes, planned stop date:

13 My family history Family history IBD: Colorectal cancer: Other malignancies (specify): Other (specify): Prescription drug insurance Prescription drug coverage plan:

14 My medication Aminosalicylates Generic name Taken in past Sulfasalazine 5-aminosalicylic acid Number of times medication has been taken in the past. Antibiotics Generic name Taken in past Ciprofloxacin Metronidazole Number of times medication has been taken in the past. Currently taking Currently taking Dosage Immunomodulators and immunosuppressants Generic name Taken in past 6-mercaptopurine Azathioprine/Imuran Methotrexate Cyclosporin Number of times medication has been taken in the past. Currently taking Dosage Dosage Side effects/ comments Side effects/ comments Side effects/ comments

15 My medication Corticosteroids Generic name Taken in past Currently taking Prednisone Methylprednisone Budesonide Number of times medication has been taken in the past 12 months. Dosage Side effects/ comments Other medications I am taking or have taken List any medications or supplements (e.g., vitamins, herbal products) you take, or have taken, for reasons other than for your disease. Brand and/or generic name Taken in past Currently taking Side effects/ comments

16 My tests Biologics Tuberculosis (TB) test Date: Result: mm quantiferon Negative Positive Chest X-ray results Date: Verified by: Normal Abnormal Comments: Others (specify) Test: Date: Result:

17 My medication Biologics Generic name Start date Stop date Concomitant immunosuppressant Side effects/ comments Adalimumab Infliximab Golimumab Vedolizumab

18 If you are currently taking a biologic for your disease, and should you develop signs or symptoms of infection (e.g., a fever) or have to take antibiotics, it is important that you speak with your doctor as soon as possible to obtain recommendations. Your biologic therapy may have to be suspended during the episode of infection. If you have any questions, do not hesitate to speak with your health care team.

19 My medical profile Immunization The tables on the next page briefly summarize the Canadian Immunization Guide recommendations for people* with a chronic inflammatory disease before and while undergoing immunosuppressive therapy.

20 Vaccine recommendations BEFORE immunosuppressive therapy Date Recommended inactivated vaccines Recommended live vaccine Pneumococcal Hepatitis B may be considered in seronegative patients Varicella (if varicella susceptible) or herpes zoster may be considered Live vaccines contain weakened forms of the organism that causes the disease and are generally contraindicated during immunosuppressive therapy. Vaccine recommendations WHILE UNDERGOING immunosuppressive therapy Recommended Trivalent inactivated influenza vaccine annually Date If you have any question about vaccination, talk to your doctor or nurse. * For children s vaccination recommendations, please talk to your doctor or nurse. Please see complete details at

21 My medical profile Immunization If you would like to know more about your provincial immunization schedule, don t hesitate to visit the vaccination Web site of your province or territory. British Columbia Alberta Saskatchewan Manitoba Ontario Quebec Newfoundland & Labrador New Brunswick Nova Scotia Prince Edward Island Yukon Nunavut Northwest Territories immunization-services#immunization-programs www2.gnb.ca/content/gnb/en/departments/ocmoh/cdc/content/immunization.html

22 Tests Diagnostic tests List any diagnostic tests (colonoscopy, upper endoscopy, calprotectin, C-reactive protein, CT or X-ray scans, ultrasound, MRI, MRE) relevant to your IBD that you have undergone. Include any important information about these tests.

23 Other important tests Depending on your treatment and/or your condition, routine testing may be recommended. List any routine examination that you have undergone. Date Results Comments Pap test* Skin examination Surveillance colonoscopy * For women

24 Useful Web sites Canadian Web sites Crohn s and Colitis Canada Canadian Digestive Health Foundation Gastrointestinal Society The IBD Foundation Gut Inspired Intestinal Disease Education and Awareness Society (IDEAS) McGill University Health Centre Mount Sinai Hospital Health Canada-Healthy Eating

25 International Web sites Crohn s and Colitis Foundation of America International Foundation for Functional Gastrointestinal Disorders Mayo Clinic MedicineNet.com MedlinePlus You and IBD An Animated Patient s Guide to Inflammatory Bowel Disease (IBD) The Web sites suggested in this brochure do not imply an endorsement of or association with third-party organizations/ Web sites and are provided for information purposes only. AbbVie is not responsible for content of non-abbvie sites.

26 Proud supporters of My IBD Passport Canadian Digestive Health Foundation (CDHF) The mission of the Canadian Digestive Health Foundation is to reduce suffering and improve quality of life by providing trusted, accessible and accurate information about digestive health and disease. The Foundation empowers Canadians to manage their digestive health with confi dence and optimism. Crohn s and Colitis Canada Crohn s and Colitis Canada is committed to educating patients, families, healthcare industry and government about IBD. Become your own health advocate by being better informed about IBD. Visit for up-to-date IBD resources. Canadian Association of Gastroenterology (CAG) The Canadian Association of Gastroenterology has over 1100 members including gastroenterologists, surgeons, pediatricians, basic scientists and nurses. CAG remains dedicated to research, professional education, and patient care in all areas of digestive health and disease, in support of the economic and social health of all Canadians. The information, opinions, recommendations and/or procedures expressed or depicted in this material do not necessarily refl ect those of the CAG.

27 Questions/notes In case of a flare, you should speak to: Name: Number: Use the space below as a memory aid to write down any questions for your health care team, concerns regarding your treatment or disease, and/or changes to your symptoms.

28

29 Appointments Date: Time: Doctor: Date: Time: Doctor: Date: Time: Doctor: Date: Time: Doctor: Date: Time: Doctor: Date: Time: Doctor: Date: Time: Doctor: Date: Time: Doctor: Date: Time: Doctor: Date: Time: Doctor:

30 MY IBD PASSPORT Developed in partnership with Dr. Desmond Leddin MB, FRCP, Professor of Medicine. AbbVie Corporation Printed in Canada HUM/3383A June 2016 abbvie.ca