This questionnaire captures patient-reported scar symptoms and concerns for structured documentation. It is not a diagnosis, treatment recommendation, or emergency triage tool.
If a patient reports urgent symptoms such as spreading infection, severe uncontrolled pain, bleeding, fever, or rapidly worsening wound problems, the clinical team should follow local escalation procedures.
Clinic staff completes this section before research export.
patient_id:lesion_id:visit_id:visit_date_offset_days:
Pain today, 0 means no pain and 10 means worst imaginable pain.
patient_reported_pain: 0 / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
Itch today, 0 means no itch and 10 means worst imaginable itch.
patient_reported_itch: 0 / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
Overall satisfaction with the scar today, 0 means not satisfied and 10 means very satisfied.
patient_satisfaction: 0 / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
Does the scar affect movement, clothing, sleep, work, exercise, or daily activity?
- No
- Yes
- Unsure
If yes or unsure, describe the issue in the patient's own words:
functional_impact:
How much does the scar appearance bother the patient today?
- Not at all
- Mildly
- Moderately
- Severely
- Not sure
Patient description of cosmetic concern:
cosmetic_impact:
Free-text patient concern for clinician review:
- Questionnaire completed by patient / caregiver / staff interview:
- Language or comprehension support needed:
- Fields missing and reason: