Date of the visit:
Date of data entry
Patient form: (History-taking)
1. How old were you when the first boil* appeared? (Years)
(*inflammatory nodule and/or abscess, usually painful)
2. How old were you when you visit a doctor, for the first time, regarding a boil?
3. How old were you when the diagnosis of Hidradenitis Suppurativa was established?
4. How long did it take from the first HS-related visit to your general practitioner till the first HS-related visit to a dermatologist?
5. Who made the diagnosis?
Specialist in infectious diseases
6. Has your hidradenitis suppurativa ever been misdiagnosed as another condition?
I do not know
hich other diagnosis was proposed?
7. How many relapses* have you experienced in the last year?
*A return of the disease after partial recovery from it
8. What is the average duration of a relapse in your case?
9. In case of a relapse, where do the boils usually appear?
Mostly at the usual locations
Mostly at new locations
At both usual and new locations
10. How many boils (new or flared existing boils) did you have during the last 4 weeks?
11. How painful was the most painful boil that bothered you the most during the last 4 weeks?
0 = no pain at all
10 = severe pain
12. How many painful days related to the disease did you have during the last 4 weeks?
13. Which kind of pain is associated with your disease?
14. How much suppuration was produced by the boil that bothered you the most during the last 4 weeks?
0 = no suppuration
10 = a lot of suppuration
15. How has your disease developed since it started?
it has remained stable
it has become worse
It has improved (decreased in severity)
16. Have you ever had fever episodes during inflammatory HS outbreaks?
17. Have you ever been absent from work because of your HS?
How many days of absence from work have you had due to HS during your whole working life (roughly)?
How many days of absence from work have you had due to HS during the last 6 months?
18. Has your professional career been influenced by the disease?
Not at all
Yes, a little
Yes, a lot
19. Aggravating factors/ triggers of flare up:
Food and drinks
AINS Non-steroidal anti drugs (such as ibuprofen, novaminsulfone)
Pressure or mechanic friction (e.g., friction through tight clothing, underwear)
No aggravating factors
20. Does your menstruation have an effect on acne inversa?
I do not have menstruation anymore
Have you ever been pregnant?
How many times?
Did being pregnant influence the severity of your hidradenitis suppurativa?
--Select an option--
The disease had not begun yet