Patient name: | Date (dd/mm/yyyy): _____ /_____ /_____ |
Date of birth (dd/mm/yyyy): _____ /_____ /_____ |
Instructions: You have urticaria. 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 do not think about the questions for a long time, and do remember to answer all questions and to provide only one answer to each question. |
| 0 points | 1 point | 2 points | 3 points | 4 points | Scoring |
- How much have you suffered from the physical symptoms of urticaria (itch, hives [welts], and/or swelling) in the last four weeks?
| Very much | Much | Somewhat | A little | Not at all | |
- How much was your quality of life affected by the urticaria in the last four weeks?
| Very much | Much | Somewhat | A little | Not at all | |
- How often was the treatment for your urticaria in the last four weeks not enough to control your urticaria symptoms?
| Very often | Often | Sometimes | Seldom | Not at all | |
- Overall, how well has your urticaria been under control in the last four weeks?
| Not at all | A little | Somewhat | Well | Very well | |
| Total points: | |