Doctor Visit Questionnaire

Psoriasis is a painful and stressful enough disease without a visit to your physician adding to your troubles. And from what we hear, while overall patient satisfaction with physicians is high, many people report feeling rushed during their visits to the doctor.

This web questionnaire can help. Simply answer the questions below, click SUBMIT, and then print out the results. Take the results with you to your next appointment.

This will give your physician and his or her staff some of the background facts they need to evaluate your condition fully. This is not a comprehensive list of issues to discuss with your doctor, and it should not replace one-on-one time with your physician, but it can help ensure that important issues do not get overlooked in the haste that is often a feature of our health care system today.

All the questions are optional. Now let’s get started:

1. Enter your first name or initials (please do not use your last name):

2. Where do you currently have psoriasis on your body?

Arms Legs Chest Back Buttocks Scalp Face Hands Nails Feet Groin/genitals

3. Over the last month, how much of a problem has psoriasis been in your life?

------- No problem A little problem A significant problem A serious problem

4. Over the last month, how much of a problem has itch been for you?

------- No problem A little problem A significant problem A serious problem

5. Over the last month, how much of a problem has skin pain, soreness, cracking and/or bleeding been for you?

------- No problem A little problem A significant problem A serious problem

6. Over the last month, have you experienced any of the following?

Arthritis Joint pain Back pain Morning stiffness

7. Over the last month, how much of a problem has fatigue/tiredness been for you?

------- No problem A little problem A significant problem A serious problem

8. Over the last month, how much has your psoriasis interfered with your work?

------- None A little Significantly Seriously

9. Over the last month, how often have you hidden or tried to hide your psoriasis through choice of clothes, make-up or other methods?

------- Not at all Seldom Occasionally Often Most of the time

10. Over the last month, how much has psoriasis interfered with your interest in or ability to meet new people and/or meet with clients, coworkers and others?

------- None A little Significantly Seriously

11. Over the last month, has psoriasis brought on any problems with intimacy or sexual difficulties?

------- No problem A little problem A significant problem A serious problem

12. Over the last month, how often have you felt angry, irritable or guilty?

------- Not at all Seldom Occasionally Often Most of the time

13. Over the last month, how often have you felt sad, ‘down in the dumps’ or had feelings of hopelessness?

------- Not at all Seldom Occasionally Often Most of the time

14. Over the last month, how often have you been eating or sleeping either too little or too much?

------- Not at all Seldom Occasionally Often Most of the time

15. Please list other medications you are currently taking or applying regularly for psoriasis or for other reasons. Include nutritional supplements, over-the-counter and alternative meds:

16. Is or are your current psoriasis treatment(s) causing side effects for you? Explain.

17. On a scale of 1 to 10, with a "10" meaning you are completely satisfied with your current psoriasis treatment(s), and a "1" meaning you desperately want to try a different treatment, how would you currently rate your treatment(s)?

------- 1 2 3 4 5 6 7 8 9 10

18. Finally, check any of the boxes that apply to you. Do you:

Smoke tobacco Have high cholesterol Have high blood pressure Have diabetes

19. Feel free to add here any additional comments that you want to be sure your physician sees. If you may be considering conceiving a child during the next year, please note that here:

In order to prevent spam, please type the words you see below into the box.

Now you are ready to print out your completed form. Simply click Submit and a printer-friendly summary of your responses will appear in a few moments. Print it out and remember to bring it to your next doctor visit!

If you have any comments or suggestions regarding how we can improve this Doctor Visit Questionnaire, email us at comments @ psoriasis-cure-now.org. Thanks.