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Patient CRF - Visit

Date of visit

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Subject ID

In Project ID

Gender

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Age

Inclusion

Page

Site

Status

l. Spreading of psoriasis plaque

1. Please draw your skin changes as accurately as possible on the figures. You only need to outline the affected areas.

Paint

2. How do your rate the severity of your psoriasis at the moment?

Please choose the appropriate place on the line from 0-10:

0 - No changes to skin 10 - Most intense changes to skin

If you have joints involved (psoriatic arthritis):

3. How do your rate the severity of your psoriatic arthritis at the moment?

Please mark the corresponding number:

Pain psoriatic arthritis

0 - No pain 10 - Severe pain

Activity psoriatic arthritis

0 - No activity 10 - Severe activity