NASPGHAN Personal IBD Notebook Download

As a parent whose child has been diagnosed with Crohn’s Disease or Ulcerative Colitis, you want to do whatever you can to help your child. But there are so many new things to do and to learn about: new medications, new tests, new doctors and nurses. It can be hard to keep track of all this information. The Personal IBD Notebook contains important information for families about IBD, and is a great place to store vital information about your child’s disease, such as the details about diagnosis, medications, lab reports, and procedures. By keeping your Personal IBD Notebook up to date, you will learn about IBD and will always have important information when you need it. NASPGHAN would like to help by allowing you to download the contents of the Personal IBD Notebook. We would also like to be able to inform you of new developments in treatment and research in IBD when they occur. To download your personal IBD Notebook contents and to receive future updates about developments in IBD without any cost, complete the following information, which will be kept confidential and is for use only by NASPGHAN.

Child's First Name
Middle Initial
Child's Last Name
Parent/Guardian's First Name	*
Parent/Guardian's Middle Initial
Parent/Guardian's Last Name	*
Mailing Address
City
State/Province
Country
Zip/Postal Code
Parent/Guardian's E-mail Address	*
Child's Birthdate	(month/day/year) *
When was your child's Crohn's Disease or Ulcerative Colitis diagnosed?
(month/day/year) *
Does your child have: *
Crohn's Disease     Ulcerative Colitis    Unsure
Your GI Doctor's Name	*
Your GI Doctor's Hospital	*
Please check either yes or no: *
Yes, I would like to be on a mailing list to receive updates about new treatments and research in IBD.
No, I do not want to receive future updates.
* Indicates a response is required

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