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 | |
| Very much | Much | Somewhat | A little | Not at all | |
| Very much | Much | Somewhat | A little | Not at all | |
| Very often | Often | Sometimes | Seldom | Not at all | |
| Not at all | A little | Somewhat | Well | Very well | |
Total points: |
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