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X

i

Visit

Date of visit

* / / *

Subject ID

In Project ID

Gender

M

F

Age

Date of Inclusion

Page

Site

Status

1. Interim medical history

Have there been changes in the psoriasis regarding the clinical type since the patient's last interview?

Yes

No

If yes, current clinical type?

Nails affected

Yes

No

To determine how much percentage affected the nail area, the nails must be divided into four quadrants (corresponding to 25% of the nail area per square).

If yes: number of affected fingernails

1-10 Finger

Of these:

Completely (>90%) affected

1-10 Finger

50-90% affected

1-10 Finger

Below 50% affected

1-10 Finger

BSA (Body Surface Area (BSA))

Calculation of percent body surface area affected by psoriasis. For more information on the BSA, please click here.

0-100%

Have there been any changes in the concomitant illness since the last patient's visit?

Yes

No

If yes, add an additional "UI" form (Undesired Incidents) on page 6 during this visit.

Have there been any changes to long-term medication (not psoriasis) since the last interview with the patient?

Yes

No

Which medication (Dosage) is new?

Product name

on

/ /

Product name

on

/ /

Product name

on

/ /

Product name

on

/ /

Product name

on

/ /

Which medication was discontinued?

Product name

on

/ /

Product name

on

/ /

Product name

on

/ /

Product name

on

/ /

Product name

on

/ /