Generic Skin Care Questionnaire And Assessment Page 2
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1
2
3
4Reviewed by:
General Questions
1. Have you had skin problems previously?
Yes. Please describe:
No
2. Can you use all the healthcare supplied hand hygiene products without pain or restrictions?
Yes
No
Unsure
3. Do you experience problems with your hands following the use of alcohol based hand rub (ABHR)?
Yes
Go to Q3a
No
Go to Q.4
Unsure
a. How soon after the application of ABHR do you experience problems with your hands?
_______________________________________________________________________
b. How you reported this?
Yes. To whom?___________________________
No
4. Do you experience problems with your hands following the use of soap products?
Yes
Go to Q4a
No
Go to Q.5
Unsure
a. How soon after the application of soap do you experience problems with your hands?
________________________________________________________________________
b. How you reported this?
Yes. To whom?___________________________
No
5. Do you experience problems with your hands following the use of moisturiser?
Yes
Go to Q5a
No
Go to Q.6
Unsure
a. How soon after the application of moisturiser do you experience problems with your hands?
________________________________________________________________________
b. How you reported this?
Yes. To whom?___________________________
No
6. During a shift how many times do you use an ABHR?
Never
Yes. Indicate an approximate number:___________________
7. During a shift how many times do you wash your hands?
Never
Go to Q.8
Yes. Indicate an approximate number:___________________
a. Do you thoroughly dry your hands with paper towel after each wash?
Yes
No
Sometimes
b. Do you wet your hands before applying soap?
Yes
No
Sometimes
8. During a shift do you wear gloves?
Yes
Go to Q8a
No
Go to Q.9
Sometimes
Go to Q8a
a. During a shift how often would you wear gloves
Rarely
Sometimes
Frequently
9. During a shift how many times do you use a hospital supplied moisturiser?
Never
Yes. Indicate an approximate number:___________________
10. At home how many times do you use an ABHR in a 24hr period?
Never
Yes. Indicate an approximate number:___________________
11. At home how many times do you wash your hands in a 24hr period?
Never
Yes. Indicate an approximate number:___________________
12. At home do you wear gloves for wet or abrasive tasks e.g. washing up, gardening?
Yes
Go to Q12a
No
Go to Q.13
Sometimes
Go to Q12a
a. At home how often would you wear gloves for these tasks
Rarely
Sometimes
Frequently
13. At home how many times do you use a moisturiser in a 24hr period?
Never
Yes. Indicate an approximate number:___________________
14. Does your skin condition improve during days off &/or holidays?
Yes
No
Sometimes
Document reviewed Nov 2012
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