Patient Questionnaire – Chronic Urticaria

Patient Questionnaire – Chronic Urticaria
(Follow Up)
Dear Patient,

Please answer the following questions regarding the present situation of your Chronic Urticaria and its course since the last consultation.

Please remember that Urticaria comes with wheals, angioedema (swelling), or both. Wheals and angioedema are often confused. Below you find typical pictures of wheals and angioedema. These pictures are meant to help you to answer the questions of this questionnaire correctly.

Wheals (pinhead-sized up to many cm in diameter, strictly delimited, occasionally streak shaped, mostly itching, reddish, transient, raised skin lesions lasting minutes up to many hours
Angioedema (usually skin colored, mostly hard to delimit, sometimes painful swelling of the skin or mucous membranes, for example of the eyelids, lips, tongue, hands or feet; can last for several hours to days)
The more we know about your urticaria the better. Therefore, please answer all of the following questions. Should you be unsure about how to answer to some of the questions, please don’t hesitate to discuss this with us.
Date:

DayMonthYear
Date
Name

First NameLast Name
Date of Birth:

DayMonthYear
Date
How tall are you and how much do you weigh?
Height in centimetres
Weight in kilograms
2 Did your Urticaria stop since the last consultation?

yesno
If yes, when did it stop?
Month
Year
If no, what currently applies to your urticaria? (please mark all applicable answers)

my skin symptoms of urticaria appear spontaneously, I cannot trigger them through specific stimuliI can induce urticaria through specific stimulations (e.g. scratching, prolonged pressure, cold contact, strenuous exercise)
If yes, through which stimuli:
If your skin symptoms of the Urticaria are spontaneous as well as specifically triggered, which of the two is currently predominant?

spontaneously appearing skin symptomsinducible skin symptomsI don’t know
Exactly which skin symptoms of the Urticaria have you had since the last consultation?

Wheals (pinhead-sized up to many cm in diameter, strictly delimited, occasionally streak shaped,mostly itching, reddish, transient, raised skin lesions lasting minutes up to many hours)Angioedema (usually skin colored, mostly hard to delimit, sometimes painful swelling of the skin or mucous membranes, for example of the eyelids, lips, tongue, hands or feet, can last for several hours or days)
Both
Since the last consultation, did the skin symptoms of your Urticaria itch?

YesNo
If yes, how much during the past 7 days:

no itch during past 7 daysmild itchmoderate itchintense itch
(mild itch = present but not annoying or troublesome, moderate itch = troublesome but does not interfere with normal daily activity or sleep, intense itch = sufficiently troublesome to interfere with normal daily activity or sleep)
Since the last consultation, did you have Urticaria symptoms continuously?

yes, I have had continuous urticaria symptoms since the last consultationno, there are/has been a longer period/periods (of at least 2 weeks) without urticaria
In the past 4 weeks, did your Urticaria symptoms appear every day or almost every day?

YesNo
In the past 4 weeks, on average, on how many days per week did you have Urticaria symptoms?

0 days1 day2 days3 days4 days5 days6 days7 days
Did you suffered from wheals since the last consultation? How often have you experienced wheals in the last 4 weeks?

No wheals1-3 days4-6 days7-13 days14-20 days21-27 daysevery day
How long would a single wheal take to resolve?

Less than 1 hour1-6 hours6-12 hours12-24 hours24-48 hours48-72 hoursmore than 72 hours
In the past weeks, how many days have you experienced angioedema?

0 days1 day2-3 days4-6 days7-13 days14 days or more
In the past 4 weeks, how long did it usually take for single angioedema to completely disappear?

No angioedemaLess than hour1-6 hours6-12 hours12-24 hours24-48 hours48-72 hoursMore than 72 hours
On which body parts did angioedema appear since the last consultation?

No angioedemaEyelidsLipsRest of faceTongueLarynxHandsFeetGenitalsOther
Since the last consultation, did you become aware of any new factors which can make your urticaria or angioedema worse? e.g. infection, medication, foods, stress, insect bites
Urticaria Control Test

The following questions should help us understand your current health situation.

Please read through each question carefully and choose an answer from the five options that best fits your situation. Please limit yourself to the last four weeks.

Please don’t think about the questions for a long time, and do remember to answer all questions and to provide only one answer to each question.
How much have you suffered from the physical symptoms of the urticaria (itch, hives (welts) and/or swelling) in the last four weeks?

Very muchMuchSomewhatA littleNot at all
How much was your quality of life affected by the urticaria in the last 4 weeks?

Very muchMuchSomewhatA littleNot at all
How often was the treatment for your urticaria in the last 4 weeks not enough to control your urticaria symptoms?

Very oftenOftenSometimesSeldomNot at all
Overall, how well have you had your urticaria under control in the last 4 weeks?

Not at allA littleSomewhatWellVery well
How often in the last 7 days was your sleep disturbed by Urticaria symptoms?

none1 night2 nights3 nights4 nights5 nights6 nights7 nights
Since the last consultation, did any new diseases occur?

YesNo
If yes, which diseases:
Since the last consultation, did any of your diseases, besides Urticaria, disappear?

YesNo
If yes, which diseases
15 Since the last consultation, did your regular medication (other than for Urticaria) change?

yesnoI do not take such medication
If yes, what has changed?
Is your Urticaria presently (in the last 4 weeks) treated with medication?

YesNo
If yes, name of medication and dose and frequency:
Success of treatment

Good success (reduction of symptoms by at least 90%)Partial success (reduction of symptoms, but by less than 90%)No reduction of symptoms
Since the last consultation, has your Urticaria been treated with any other medication than mentioned in the last question?

NoYes
Other medication details:
Include dose, frequency, success and any side effects
Further medication details if used:
Include dose, frequency, success and any side effects
Additional therapies:
Since the last consultation, did you have consulted any other doctors for your urticaria or angioedmema?

NoGeneral PractitionerDermatologistPaediatricianENT specialistOther
Since the last consultation, which diagnostic measures have been carried out by other doctors to find the cause of your urticaria and with what results?
Since the last consultation, were you treated in a hospital as an in-patient for your urticaria or angioedema?

NoYes
Since the last consultation, have you visited an emergency room or first aid station for your urticaria or angioedema?

NoYes
If yes, how many times?
Since the last consultation, have you missed school or work days due to your urticaria or angioedema?

YesNoI do not attend work/school
If yes, how many days did you miss in the past 12 months?
Should be Empty:

Patient Questionnaire – Chronic Urticaria

(Follow Up)