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Visit
Date of the visit:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
*
/
*
/
*
Subject ID
Gender
M
F
Age
Site
Page
Date of data entry
Doctor Follow-up
Complementary exams
Did you give a blood sample since your last visit?
Yes
No
Specify the date:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Unknown (nk)
*
/
/
*
CRP:
mg/dl
Leucocytes:
mrd/l
HbA1C:
mg/dl
HDL:
mg/dl
LDL:
mg/dl
Triglyceride:
mg/dl
Blood pressure:
/mmHg
/
/mmHg
Waist circumference:
Waist circumference:
cm
Height:
cm
Weight:
kg
Body mass index:
Body mass index:
Physical examination
Absence of lesions
Where are your lesions located now?
Scalp
Inflammatory nodules
Abscesses
Draining fistula
Non draining fistula
Fibrotic scars
Other:
Are the lesions separated clearly by normal skin?
Yes
No
Largest distance between 2 lesions (or size if only one lesion):
< 5 cm
5 - 10 cm
> 10 cm
Left arm
Inflammatory nodules
Abscesses
Draining fistula
Non draining fistula
Fibrotic scars
Other:
Are the lesions separated clearly by normal skin?
Yes
No
Largest distance between 2 lesions (or size if only one lesion):
< 5 cm
5 - 10 cm
> 10 cm
Right arm
Inflammatory nodules
Abscesses
Draining fistula
Non draining fistula
Fibrotic scars
Other:
Are the lesions separated clearly by normal skin?
Yes
No
Largest distance between 2 lesions (or size if only one lesion):
< 5 cm
5 - 10 cm
> 10 cm
Right gluteus
Inflammatory nodules
Abscesses
Draining fistula
Non draining fistula
Fibrotic scars
Other:
Are the lesions separated clearly by normal skin?
Yes
No
Largest distance between 2 lesions (or size if only one lesion):
< 5 cm
5 - 10 cm
> 10 cm
Left gluteus
Inflammatory nodules
Abscesses
Draining fistula
Non draining fistula
Fibrotic scars
Other:
Are the lesions separated clearly by normal skin?
Yes
No
Largest distance between 2 lesions (or size if only one lesion):
< 5 cm
5 - 10 cm
> 10 cm
Perianal
Inflammatory nodules
Abscesses
Draining fistula
Non draining fistula
Fibrotic scars
Other:
Are the lesions separated clearly by normal skin?
Yes
No
Largest distance between 2 lesions (or size if only one lesion):
< 5 cm
5 - 10 cm
> 10 cm
Left leg
Inflammatory nodules
Abscesses
Draining fistula
Non draining fistula
Fibrotic scars
Other:
Are the lesions separated clearly by normal skin?
Yes
No
Largest distance between 2 lesions (or size if only one lesion):
< 5 cm
5 - 10 cm
> 10 cm
Right leg
Inflammatory nodules
Abscesses
Draining fistula
Non draining fistula
Fibrotic scars
Other:
Are the lesions separated clearly by normal skin?
Yes
No
Largest distance between 2 lesions (or size if only one lesion):
< 5 cm
5 - 10 cm
> 10 cm
Face
Inflammatory nodules
Abscesses
Draining fistula
Non draining fistula
Fibrotic scars
Other:
Are the lesions separated clearly by normal skin?
Yes
No
Largest distance between 2 lesions (or size if only one lesion):
< 5 cm
5 - 10 cm
> 10 cm
Right axila
Inflammatory nodules
Abscesses
Draining fistula
Non draining fistula
Fibrotic scars
Other:
Are the lesions separated clearly by normal skin?
Yes
No
Largest distance between 2 lesions (or size if only one lesion):
< 5 cm
5 - 10 cm
> 10 cm
Left Axila
Inflammatory nodules
Abscesses
Draining fistula
Non draining fistula
Fibrotic scars
Other:
Are the lesions separated clearly by normal skin?
Yes
No
Largest distance between 2 lesions (or size if only one lesion):
< 5 cm
5 - 10 cm
> 10 cm
Right breast
Inflammatory nodules
Abscesses
Draining fistula
Non draining fistula
Fibrotic scars
Other:
Are the lesions separated clearly by normal skin?
Yes
No
Largest distance between 2 lesions (or size if only one lesion):
< 5 cm
5 - 10 cm
> 10 cm
Left breast
Inflammatory nodules
Abscesses
Draining fistula
Non draining fistula
Fibrotic scars
Other:
Are the lesions separated clearly by normal skin?
Yes
No
Largest distance between 2 lesions (or size if only one lesion):
< 5 cm
5 - 10 cm
> 10 cm
Trunk
Inflammatory nodules
Abscesses
Draining fistula
Non draining fistula
Fibrotic scars
Other:
Are the lesions separated clearly by normal skin?
Yes
No
Largest distance between 2 lesions (or size if only one lesion):
< 5 cm
5 - 10 cm
> 10 cm
Genital
Inflammatory nodules
Abscesses
Draining fistula
Non draining fistula
Fibrotic scars
Other:
Are the lesions separated clearly by normal skin?
Yes
No
Largest distance between 2 lesions (or size if only one lesion):
< 5 cm
5 - 10 cm
> 10 cm
Right groin
Inflammatory nodules
Abscesses
Draining fistula
Non draining fistula
Fibrotic scars
Other:
Are the lesions separated clearly by normal skin?
Yes
No
Largest distance between 2 lesions (or size if only one lesion):
< 5 cm
5 - 10 cm
> 10 cm
Left groin
Inflammatory nodules
Abscesses
Draining fistula
Non draining fistula
Fibrotic scars
Other:
Are the lesions separated clearly by normal skin?
Yes
No
Largest distance between 2 lesions (or size if only one lesion):
< 5 cm
5 - 10 cm
> 10 cm
Folliculitis of the scalp:
Yes
No
If yes:
Dissecting
Other:
More than 10 inflammatory lesions?
Yes
No
If yes:
True typical acne
Acne/HS
Hurley - Score:
I
II
III
HS-PGA Score
Clear
HS-PGA Score
Mild
HS-PGA Score
Moderate
HS-PGA Score
Severe
HS-PGA Score
Very severe
IHS4
Mild HS
Moderat HS
Severe HS
Sartorius Score:
Subclinical variant:
Axillary–mammary
Follicular
Gluteal
Other
Other:
Total Nodules
Total abscesses
Total fistulas
Non-draining fistulas
Draining fistulas
Total scars
Total Other
Version 4_UKE_Nov2022
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