My patient follow-up diary
risk factors
0 1 2 3 4
(scale with 0 the lower and 5 the higher OR with 0 = no and 4 = Yes)
For all the questions
Questionnaire on risk factors with an analyse at the end, to have a pourcentage + use a graph to illustrate the results
Homme ou Femme
1) excessive consumption of alcohol (more than 2 to 3 drinks of alcohol by day)?
2) smoker ?
3) stressed ?
4) tired ?
5) Menstruation?
0 = no
1 = last year
2 = last month
3 = last week
4 = yes, today
0 = no
1 = last week
2 = 3 days ago
3 = yesterday
4 = today
6) Skin flakes
7) itching ? cutaneous irritation ?
0 = none
1
2
3
4 = serious, red, and dry skin
8) Did you take any medication such as :lithium, betablockers, anti-malaria, interferons, antiinflammatory, angiotensin converting enzyme (hypertension) ?
0 = no
1 = last year
2 = last month
3 = last week
4 = yes, today
9) forget your treatment ?
0 = no
1
2
3
4 = yes
10) confront to a cold dry climate ?
11) experience of sunburn ?
0 = no
1 = last year
2 = last month
3 = last week
4 = yes, today
12) experience of sore throat?
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