Patient Questionnaire – Chronic Urticaria - Initial Assessment

  • Patient Questionnaire – Chronic Urticaria

  • (Initial Baseline)

  • Dear Patient,

    Your answers to the following questions regarding the present situation of your Chronic Urticaria and its course up to now can help to better manage your disease.

    Before you start to answer these questions: Patients with urticaria can have wheals, angioedema (swelling), or both. These two disease signs 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 4
  • Image field 6
  • Image field 8
  • Image field 10

  • 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 13
  • Image field 15
  • Image field 17

  • To ensure that we can give you the best possible treatment, it is necessary that we receive as much information as possible about your Urticaria (hives). Therefore, we ask you to 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
     - -
  • When did you experience symptoms of your Urticaria for the first time?
     - -
  • First diagnosed with urticaria or angioedema by

  • When was the first time a doctor diagnosed the urticaria or angioedema?
     - -
  • What applies to your Urticaria?
  • Exactly which skin symptoms of the urticaria are you experiencing?
  • Do the skin symptoms of your urticaria itch?
  • Does your urticaria burn rather than itch?
  • Does your urticaria leave bruises?
  • If you suffer from wheals, how long do single wheals usually last until they completely disappear?
  • If you suffer from wheals, how large do they get normally?

  • If you suffer from angioedema (definition see question 5 and picture on first page), how long do single angioedema usually last until they completely disappear?
  • If you suffer from angioedema, on which body parts have they already appeared?

  • If you suffer from wheals and angioedema, which symptom appeared first during the course of disease?
  • If one symptom appeared first, when did the second symptom appear?
  • Did angioedema appear only within the first 6 weeks of your Urticaria?
  • Please state if, in addition to wheals and/or angioedema, you are also suffering from the symptoms below:
  • Have you ever been diagnosed with a malignancy/cancer?
  • Have you ever collapsed, felt faint or breathless with urticaria?
  • Do you suffer from emotional problems or mental illness? (for example depression, anxiety disorders)
  • Do you suffer from chronic infections? (e.g. virus hepatitis)
  • Do you suffer from gastrointestinal complaints?
  • Do you take medication on a regular basis? (apart from medication for urticaria)
  • Are the symptoms of your Urticaria getting worse after taking pain relievers?
  • Is your Urticaria presently treated with medication?
  • Mode of intake:

  • Success of treatment:
  • Side effects of the treatments:
  • Has your Urticaria been treated differently with medication before?
  • Success of treatment
  • Has your Urticaria ever been treated with approaches not using medication? (e.g. diets, naturopathic treatment, acupuncture)
  • What do you believe initially caused your Urticaria?

  • Which of the following factors can make your Urticaria worse or can cause an exacerbation?

  • Since the beginning of your Urticaria, have you had continuous urticaria symptoms?
  • Which of the following statements describes what happens to your Urticaria during menstruation?
  • Do you suffer from allergies, asthma or atopic dermatitis?
  • How much you suffered from the physical symptoms of the urticaria (itch, hives, 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?
  • Is your sleep disturbed by your Urticaria symptoms?
  • If yes, how many nights, of the past 7 days, were disturbed by your Urticaria symptoms?
  • In the past 12 months, have you missed school or work days due to your Urticaria?
  • In the past 12 months, which doctors have you consulted for your urticaria?

  • In the past 12 months, have you visited an emergency room or first aid station for your Urticaria?
  • In the past 12 months, were you treated in a hospital as an in-patient for your Urticaria?

  • In the following, we ask you for additional information with regard to the past 4 weeks.

    This relates to your overall urticaria symptoms (itching, wheals and/or angioedema), but also to the isolated analysis of wheals and angioedema:

     

  • 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?
  • At which time of day or night are your Urticaria symptoms usually appearing?
  • If you suffer from wheals, in the past 4 weeks, on how many days did you have wheals?
  • If you suffer from wheals, in the past 4 weeks, how long did it usually take for the single wheal to completely disappear?

  • If you suffer from angioedema:

  • In the past 4 weeks, on how many occasions did you have angioedema?
  • In the past 4 weeks, how long did it usually take for a single angioedema to completely disappear?
  •  
  • Should be Empty: