DERMATOLOGY QUESTIONAIRE ASHU SKIN CARE: Name: Address:
Date: Diagnosis:
Score:
The aim of this questionnaire is to measure how much your skin problem has affected your life. Please check one box for each question.
Tell me about the issues you’ve been experiencing ? (Histroy of Present Illness) Where is the skin lesion?” “When did you first notice the skin lesion?”
Are There any other symptômes that seem associated with the rash?”
CVS:- CHEST PAIN, PALPITATION PS:- COUGH. EXPOTRATION,
How does the skin lésion feel when you touch it?” “How many of the skin lesions are there & Shape?
HISTORY OF EXPOSURES
1. ONSET OF SKIN LESION ; •SUDDEN •GRADUAL 2. DURATION OF SKIN LESION : •DAYS •MONTHS 3. FIRST EPISODE (DATE) 4. EVOLUTION OF INDIVIDUAL LESIONS 5. EXACERBATING FACTORS : • SUNLIGHT• HEAT • COLD• PERIOD (F) 6. DISTRIBUTION ; SPREAD IN WHICH AREA • FACE• BODY • HAND• LEGS • OTHER • ITCHING• PAIN• NUMBNESS• FEVER • JOINT PAIN• HAIR LOSS• BLEEDING • BLISTERING• DISCHARGE• WT. LOSS •CHANGES IN SKIN COLOR •HEADACHE • NASAL CONGESTION •THROAT PAIN •CHANGES IN HAIR •REDUCED APETITE
Not relevant
•ELEVATED, •NORMAL, •BLISTERS Not relevant •ONE, •A FEW,
•MANY
•ROUND, •IRREGULAR, •NO DEFINITE SHAPE • FOOD - NON VEG - EGG, FISH. MUTTON.