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Get and Sign Gastroenterology Intake Form
Crohn’s large
Severity type:
mild
moderate to severe
fistulizing
Has the patient had a NEGATIVE tuberculin
skin test, or if positive, has treatment for latent
TB been initiated prior to anti-TNF therapy?
yes
no
Test Date: ________
Other: ___________________________________________
Does the patient have
NYHA Class III/IV CHF?
yes
no
Does the patient have a clinically
important active infection?
yes
no ______________
For moderate to severe Crohn’s disease:
Has patient failed/contraindicated...
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