Patient Questionnaire – Chronic Urticaria

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)
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)
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

DayMonthYear
Date
Name

First NameLast Name
Date of birth

DayMonthYear
Date
Height in centimetres
Weight in kilograms
When did you experience symptoms of your Urticaria for the first time?

DayMonthYear
First diagnosed with urticaria or angioedema by

Not yet formally diagnosedImmunologist/AllergistGeneral PractitionerDermatologistOther
When was the first time a doctor diagnosed the urticaria or angioedema?

DayMonthYear
What applies to your Urticaria?

Skin symptoms appear spontaneously, I cannot trigger them through specific stimuliI myself can induce my skin symptoms through specific stimulation e.g.scratching, prolonged pressure, cold contact, strenuous exercise)Both spontaneous and specifically triggered
Please detail any recognized triggers
Exactly which skin symptoms of the urticaria are you experiencing?

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 coloured, mostly hard to delimit, sometimes painful swelling of the skin or mucous membranes, for example of the eyelids, tongue, hands or feet; can last for several hours to days)Both
Do the skin symptoms of your urticaria itch?

NoYes
Does your urticaria burn rather than itch?

NoYes
Does your urticaria leave bruises?

NoYes
If you suffer from wheals, how long do single wheals usually last until they completely disappear?

less than 1 hour1-6 hours6-12 hours12-24 hours24-72 hoursmore than 72 hours
If you suffer from wheals, how large do they get normally?

equal or smaller than 5 mmlarger than 5 mm
If you suffer from wheals, where do they normally appear?

The entire bodyOther
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?

less than 1 hour1-6 hours6-12 hours12-24 hours24-72 hoursmore than 72 hours
If you suffer from angioedema, on which body parts have they already appeared?

EyelidsLipsRest of the faceTongueLarynxHandsFeetGenitalsOther
If you suffer from wheals and angioedema, which symptom appeared first during the course of disease?

initially only wheelsinitially only angioedemaboth symptoms appeared from the beginning
If one symptom appeared first, when did the second symptom appear?

within 3 monthsafter 4-12 monthsafter more than 1 year
Did angioedema appear only within the first 6 weeks of your Urticaria?

YesNo
Please state if, in addition to wheals and/or angioedema, you are also suffering from the symptoms below:

Recurrent unexplained feverJoint, bone and/or muscle painGeneral recurrent discomfort (malaise)Weight loss
Have you ever been diagnosed with a malignancy/cancer?

NoYes
Please provide any details:
Have you ever collapsed, felt faint or breathless with urticaria?

YesNo
If yes, please describe
Which other diseases, besides Urticaria, do you have?
Do you suffer from emotional problems or mental illness? (for example depression, anxiety disorders)

YesNo
If yes, please specify:
Do you suffer from chronic infections? (e.g. virus hepatitis)

NoYes
If yes, which ones?
Do you suffer from gastrointestinal complaints?

NoYes
If yes, please specify:
Do you take medication on a regular basis? (apart from medication for urticaria)

NoYes
If yes, which medication?
Are the symptoms of your Urticaria getting worse after taking pain relievers?

NoYes
If yes, after which pain relievers:
Is your Urticaria presently treated with medication?

NoYes
If yes, name of medication:
Mode of intake:

1x daily2x daily3x daily4x dailyas neededOther
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
Side effects of the treatments:

NoYes
If yes, please specify:
Has your Urticaria been treated differently with medication before?

NoYes
If yes, please detail the medication, strength and dosing:
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
Any side effects of treatment:
Additional therapies:
Has your Urticaria ever been treated with approaches not using medication? (e.g. diets, naturopathic treatment, acupuncture)

yesno
If yes, please specify?
What do you believe initially caused your Urticaria?

Completely spontaneous with no apparent triggerInfectionMedicationFoodsStressOther
Which of the following factors can make your Urticaria worse or can cause an exacerbation?

InfectionMedicationFoodsStressInsect bitesI don't know of any factors that make my Uricaria worseOther
Since the beginning of your Urticaria, have you had continuous urticaria symptoms?

yes, I have had continuous urticaria symptoms since the beginning of the Urticarano, there are/has been a longer period/periods (of at least 2 weeks) without urticaria
Which of the following statements describes what happens to your Urticaria during menstruation?

my Urticaria improvesmy Urticaria worsensno change of my Urticariaquestion doesn’t apply to me
Do you suffer from allergies, asthma or atopic dermatitis?

NoYes
If yes, from which allergies or which of the above mentioned diseases?
Have any investigations been carried out already to find the cause of your urticaria and with what results?
How much you suffered from the physical symptoms of the urticaria (itch, hives, 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
Is your sleep disturbed by your Urticaria symptoms?

yesno
If yes, how many nights, of the past 7 days, were disturbed by your Urticaria symptoms?

none1 night2 nights3 nights4 nights5 nights6 nights7 nights
In the past 12 months, have you missed school or work days due to your Urticaria?

NoYes
If yes, how man days did you miss in the past 12 months?
In the past 12 months, which doctors have you consulted for your urticaria?

Immunologist/AllergistGeneral PractitionerDermatologistPediatricianEar, Nose and Throat specialistDentistGynecologistNoneOther
In the past 12 months, have you visited an emergency room or first aid station for your Urticaria?

NoYes
If yes, how often:
In the past 12 months, were you treated in a hospital as an in-patient for your Urticaria?

NoYes
If yes, please provide details:
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?

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
At which time of day or night are your Urticaria symptoms usually appearing?

in the morningat middayin the afternoonin the eveningduring the nightat no specific time
If you suffer from wheals, in the past 4 weeks, on how many days did you have wheals?

1-3 days4-6 days7-13 days14-20 days21-27 daysevery day
If you suffer from wheals, in the past 4 weeks, how long did it usually take for the single wheal to completely disappear?

less than 1 hour1-6 hours6-12 hours12-24 hours24-48 hours48-72 hoursmore than 72 hours
If you suffer from angioedema:
In the past 4 weeks, on how many occasions did you have 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 a single angioedema to completely disappear?

less than 1 hour1-6 hours6-12 hours12-24 hours24-48 hours48-72 hoursmore than 72 hours
Should be Empty:

Patient Questionnaire – Chronic Urticaria

(Initial Baseline)