Assessment tool for Pityriasis vesicolor (Skin Disorder) use to fill in conducting a physical assessment

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DERMATOLOGICAL ASSESSMENT FORM
BIO-DATA
Date of Assessment:_____________________________ Control No:___________________
Name:______________________________________________ Gender:_________ Age:__________
Address:______________________________________________________________________________
Name of Parent/Guardian:_______________________________________________________________
Contact Information(Cellphone No.) _______________________________
Source of Affiliation: DERM CLINIC (Name of Clinic) _______________________________________
SCHOOL(Name of School)__________________________________________
BRGY HEALTH CENTER (Name of Brgy)________________________________
OTHERS (Specify)_________________________________________________
Clinical Assessment:
A. FamilyHealthHistory (IncludingHx of Pityriasis versicolor): ___________________________
______________________________________________________________________________
______________________________________________________________________________
B. HealthHistory:__________________________________________________________________
______________________________________________________________________________
C. Any OtherExisting Illness:_________________________________________________________
______________________________________________________________________________
(Indicate anycurrentdrugs taken}__________________________________________________
Physical Exam for Pityriasisversicolor
1. Durationof SkinDisease:_____(years) ________(months) _________ (weeks) ______ (days)
2. PreviousTreatment:(Indicate drugstakenif any):______________________________________
______________________________________________________________________________
3. Number of episodes: once 2-3 times 4 & more times
4. Locationof SkinLesion:
4.1 (Mark X where the lesionisvisually locatedinthe body).
Above 12
yrs. old

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4.2 Puta check mark on the describe bodyparts(indicate posterior/anterior)where the
Lesions (inall types) ispresent.
Face Neck Shoulders Trunk
Back Abdomen Buttocks Upper limbs
Retro-auricularfolds Sub-mammaryfolds Axillae
Otherspecificbodyparts(Pls.indicate):______________________________________
5. Characteristics of the lesions: (Instruction) Rate the degree of dispersion of the lesions in
different parts of the body in a scale of 0-3 which describes the following:
Rating Description Interpretation
0 = absent = Absence of thistype of lesioninanybodyparts
1 = mild = Veryfew of thistype of lesions presence in1-2specificbody
parts
2 = moderate = some of thistype of lesionfoundin3-4 differentbodyparts
3 = severe = somany lesionsof thistype of lesion foundinmore than4
Differentbodyparts
Description 3 2 1 0
a. Erythema
b. Hyperpigmentation
c. Hypopigmentation
d. Pruritus/itchiness
e. Desquamation/scaling
Note: Eligiblesubjects were required to have at leastone of the individual signsand symptoms rated as
moderate or severe (score≥ 2) for pre-qualification beforetaking Mycological Exam.
6. Mycological Exam:
7.1 KOH Test:Date of test:____________________________________
Date the skinsample taken:____________________________
Result:______________________________________________
Clinical AssessmentPerformedby: NOTED BY THE PRIMARY RESEARCHER
________________________________ _______________________________
PrintFull Name &Affix Signature PrintFull Name &Affix Signature
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SOURCE: Talel Badri, et. al., (2016). Comparative clinical trial: fluconazole alone or associated with topical
ketoconazole in the treatment of pityriasis versicolor. Service de Dermatologie, Hôpital Habib Thameur / Faculté de
Médecine, Université LA TUNISIE MEDICALE; Vol 94 (2).

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