Patient Questionnaire – Chronic Urticaria - Follow-Up Assessment

  • 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

  • Image field 5
  • Image field 6
  • Image field 7
  • Image field 8

  • 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)

  • Image field 10
  • Image field 11
  • Image field 12

  • 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:
     / /
  • Date of Birth:
     / /

  • How tall are you and how much do you weigh?

  • 2 Did your Urticaria stop since the last consultation?

  • If yes, when did it stop? 

  • If no, what currently applies to your urticaria? (please mark all applicable answers)
  • If your skin symptoms of the Urticaria are spontaneous as well as specifically triggered, which of the two is currently predominant?
  • Exactly which skin symptoms of the Urticaria have you had since the last consultation?
  • Since the last consultation, did the skin symptoms of your Urticaria itch?
  • If yes, how much during the past 7 days:

  • (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?
  • In the past 4 weeks, did your Urticaria symptoms appear every day or almost every day?
  • In the past 4 weeks, on average, on how many days per week did you have Urticaria symptoms?
  • Did you suffered from wheals since the last consultation? How often have you experienced wheals in the last 4 weeks?
  • How long would a single wheal take to resolve?
  • In the past weeks, how many days have you experienced angioedema?
  • In the past 4 weeks, how long did it usually take for single angioedema to completely disappear?
  • On which body parts did angioedema appear since the last consultation?

  • 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?
  • How much was your quality of life affected by the urticaria in the last 4 weeks?
  • How often was the treatment for your urticaria in the last 4 weeks not enough to control your urticaria symptoms?
  • Overall, how well have you had your urticaria under control in the last 4 weeks?
  • How often in the last 7 days was your sleep disturbed by Urticaria symptoms?
  • Since the last consultation, did any new diseases occur?
  • Since the last consultation, did any of your diseases, besides Urticaria, disappear?
  • 15 Since the last consultation, did your regular medication (other than for Urticaria) change?
  • Is your Urticaria presently (in the last 4 weeks) treated with medication?
  • Success of treatment
  • Since the last consultation, has your Urticaria been treated with any other medication than mentioned in the last question?
  • Since the last consultation, did you have consulted any other doctors for your urticaria or angioedmema?

  • Since the last consultation, were you treated in a hospital as an in-patient for your urticaria or angioedema?
  • Since the last consultation, have you visited an emergency room or first aid station for your urticaria or angioedema?
  • Since the last consultation, have you missed school or work days due to your urticaria or angioedema?
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  • Should be Empty: