Suggested Data Collection Forms printable pdf download

Suggested Data Collection Forms

PREOPERATIVE HYPERHIDROSIS QUESTIONNAIRE

Name: _________________________ Date: ___________ Age: _________

Sex: Male

Female

Height: ________

Weight: _______

For each area listed, please rate the degree of sweating on a scale of 0 –10 (worst):

(10) Most bothersome/dripping

(5) Somewhat bothersome

(0) No sweating/not at all bothersome

______ right hand

______ left hand

______ right axilla (arm pit)

______ left axilla

______ face/forehead

______ right foot

______ left foot

______ other: ____________________________

When did your symptoms begin?

Childhood ( 12 years)

Adolescent years (13–18)

Adult (19 or older)

Does anyone else in your family have hyperhidrosis symptoms? No

Yes, who? _____________________________________

List any previous treatments for hyperhidrosis: __________________________________

Do you smoke currently? No

Yes, how many years: ____

How many packs/day: _____

Do you drink alcohol?

Yes, how much/often: _______________________________

Do you have any other medical problems/diagnosis? If yes, list: _______________________

Suggested Data Collection Forms