| Personal |
| Name: |
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| Date of birth: |
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| Address: |
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| Phone number: |
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| Email address: |
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| Gender: |
Male
Female
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| Place in family: (ie eldest of three, etc) |
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| Height: |
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| Colouring: (fair, dark, etc) |
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| Colour of eyes: |
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What childhood diseases/illnesses did
you have, and at what ages? |
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| History of your condition |
When do you think the lesions first
appeared? |
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| How old were you then? |
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| What made you see a doctor about them? |
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Have you ever been diagnosed as having
pityriasis lichenoides chronica or pityriasis
lichenoides et varioliformis acuta? |
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When/where were you diagnosed,
and by whom? |
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If possible, can you say what tests
were done to confirm the diagnosis? |
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How many lesions did you have when
first diagnosed? |
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| Have you kept a count since? |
Yes
No
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| Where are the lesions? |
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| Do they itch? |
Yes
No
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| When, especially? |
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Do they range in size and appearance?
Can you describe them? |
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What treatments have you had/are you
having? Please give dosages if possible. |
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| Are any of them effective? |
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| Ulceration of lesions |
| Have any lesions ulcerated? |
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| If so, where? |
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Are they lesions which have joined
together? |
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| What treatment do you have for these? |
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How often are they dressed, and with
what kind of dressing? |
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| How long do they usually last before healing? |
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How would you describe the pain from
these ulcers? (ie sore, sharp, severe,
neuropathic (nerves affected) |
|
What medications have you needed to
control the pain? |
|
| Family history |
| Is there a family history of skin problems, circulation problems
(eg raynaud's syndrome, cold feet and hands, etc), thyroid problems, hormonal imbalance, or any
other which you think may be relevant? |
|
|
| You again! |
| Does cold weather affect you? If so, how? |
|
| Would you rather be hot or cold? |
Hot
Cold
No preference
|
Do you travel much? If so, how?
(eg, car, coach, bus, air, etc) how often? |
|
Have you made any long-haul flights
before or after your diagnosis? |
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Do you see any patterns in the appearance of
your lesions? (eg in groups, along nerve lines,
more on the right or the left of your body, etc) |
|
Although stress is subjective and therefore very
hard to quantify, do you think stress has
played a part in your development of Degos? |
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Do you think any other organs are affected
apart from your skin? |
|
If so, how long after your skin
was affected did the other symptoms appear? |
Organ: after years and months |
| Organ: after years and months |
| Organ: after years and months |
| Organ: after years and months |
| How well do you feel? |
|
| Are you working? If so, what do you do? |
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What is your theory about what may have
triggered this condition in you? |
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Do you have any other theories/thoughts you
could share about how this condition came to
affect you? |
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