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Visit
Date of the visit:
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Subject ID
Gender
M
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Age
Site
Page
Date of data entry
Patient Follow-up Visits: Medical History
Personal medical history
Did you experience any other medical problem since your last visit?
Yes
No
If yes, please, specifiy:
Have you started any new other treatment that those for hidradenitis suppurativa since your last visit?
Yes
No
If yes, please refer to active ingredients only (do not use brand names).
Tobacco
Has your smoking status changed?
Yes
No
If yes, define:
I used to smoke and I have now stopped smoking
I used to smoke and I still smoke but I decreased my consumption
When:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Unknown (nk)
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Please, specify how many cigarettes do you smoke a day:
Cigarettes/day
If you quit smoking, how quitting smoking influenced the severity of your disease?
--Select an option--
Worse after quitting
No difference after quitting
Better after quitting
No more disease after quitting
Version 3_UKE_April2021
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