History screening questions
| . | Question . | No . | Yes . | NIH scoring clarifiers . |
|---|---|---|---|---|
| Skin | 1. Does any part of your skin: | |||
| a. Feel tight? | □ | □ | □ Tight unable to pinch? | |
| b. Feel raw or sore? | □ | □ | □ Ulcerated? | |
| c. Feel dry or itchy? | □ | □ | □ Severe itching? | |
| d. Have a rash? | □ | □ | ||
| e. Look like a shiny scar? | □ | □ | ||
| f. Look scaly or flaky? | □ | □ | ||
| g. Look darker or lighter than normal? | □ | □ | ||
| 2. Is your hair thinning or falling out? | □ | □ | ||
| 3. Do your nails look unusual? | □ | □ | ||
| Eyes | 4. Do your eyes: | |||
| a. Feel dry or gritty? | □ | □ | ||
| b. Have excessive tearing? | □ | □ | ||
| c. Hurt because of wind? | □ | □ | ||
| d. Have difficulty opening on waking? | □ | □ | ||
| 5. Do you use artificial tears? | □ | □ | □ ≤ 3× per day? or | |
| □ > 3× per day? | ||||
| 6. Have you had your tear ducts plugged or cauterized? | □ | □ | ||
| 7. Do you wear special eyewear or scleral lenses to relieve eye pain? | □ | □ | ||
| 8. Does your eye dryness affect your vision or prevent you from working? | □ | □ | ||
| Mouth | 9. Any mouth (or lip) sores or ulcers? | □ | □ | □ Using narcotics to relieve mouth symptoms? |
| □ Unable to eat because of pain? | ||||
| 10. Any discomfort with: | ||||
| a. Hot/cold? | □ | □ | ||
| b. Toothpaste? | □ | □ | ||
| c. Spicy food? | □ | □ | ||
| d. Soda/pop? | □ | □ | ||
| 11. Does your mouth feel dry most of the time? | □ | □ | ||
| 12. Is it difficult to open your mouth wide? | □ | □ | ||
| 13. Do mouth symptoms limit your oral intake? | □ | □ | □ Partially? □ In a major way? | |
| Sinuses | 14. Any draining of liquid into your throat? | □ | □ | |
| 15. Any sinus congestion or pain? | □ | □ | ||
| 16. Any recent sinus infections? | □ | □ | ||
| 17. Any sinus drainage surgery? | □ | □ | ||
| Gastrointestinal tract | 18. Do you have any of the following: | |||
| a. Nausea? | □ | □ | ||
| b. Vomiting? | □ | □ | ||
| c. Diarrhea? | □ | □ | ||
| d. Abdominal pain? | □ | □ | ||
| If no diarrhea, skip to question 20 | ||||
| 19. Did loose or liquid stools occur during the past week? | □ Some days? | |||
| □ Every day? | ||||
| □ Almost every day? | ||||
| □ Received intravenous or extra fluids during the past week to prevent or treat fluid loss from diarrhea? | ||||
| 20. Is your appetite: | ||||
| a. Poor or reduced from normal? | □ | □ | □ Are you easily full? | |
| b. Normal? | □ | □ | ||
| c. Increased? | □ | □ | ||
| 21. Did your lack of appetite, early fullness when eating, nausea or vomiting cause you to eat less during the past week? | □ Not applicable □ Occasionally last week? | |||
| □ Intermittently throughout the day? | ||||
| □ Persistent throughout the day? □ Almost every day last week? | ||||
| 22. How much do you normally weigh? | ________ lb/kg | |||
| 23. Have you had any recent weight loss? | □ | □ | □ How much weight loss divided by answer to question 22 × 100 = ___% loss?* | |
| 24. Is it painful to swallow? | □ | □ | ||
| 25. Do foods or pills get stuck? | □ | □ | ||
| 26. Can you easily swallow liquid/soft foods? | □ | □ | ||
| If no swallowing difficulties, skip to question 28 | ||||
| 27. During the past week swallowing difficulties occurred: | □ Occasionally? | |||
| □ Intermittently? | ||||
| □ Swallowing difficulties for almost everything on almost every day of the week these past 7 days? | ||||
| Musculoskeletal | 28. Are your arms, legs, or joints tight? | □ | □ | Affects activities of daily living: |
| □ Not at all? | ||||
| □ Moderately? | ||||
| □ Severely (unable to dress self, etc)? | ||||
| 29. Do you have muscle cramps or pains? | □ | □ | ||
| 30. Do you have muscle weakness? | □ | □ | ||
| 31. Do you have swollen feet, ankles, or joints? | □ | □ | ||
| Genitals | 32. Do you have vaginal (or penile, foreskin) dryness and/or discomfort during sexual activity or during a gynecologic examination? | □ | □ | Dryness/discomfort is: |
| □ Mild? | ||||
| □ Moderate? | ||||
| □ Severe? | ||||
| Lungs | 33. Do you get short of breath? | □ | □ | □ When at rest? |
| □ After 1 flight of stairs? | ||||
| □ When walking on flat? | ||||
| □ Using supplemental oxygen at any time? | ||||
| 34. Do you cough or wheeze? | □ | □ |
| . | Question . | No . | Yes . | NIH scoring clarifiers . |
|---|---|---|---|---|
| Skin | 1. Does any part of your skin: | |||
| a. Feel tight? | □ | □ | □ Tight unable to pinch? | |
| b. Feel raw or sore? | □ | □ | □ Ulcerated? | |
| c. Feel dry or itchy? | □ | □ | □ Severe itching? | |
| d. Have a rash? | □ | □ | ||
| e. Look like a shiny scar? | □ | □ | ||
| f. Look scaly or flaky? | □ | □ | ||
| g. Look darker or lighter than normal? | □ | □ | ||
| 2. Is your hair thinning or falling out? | □ | □ | ||
| 3. Do your nails look unusual? | □ | □ | ||
| Eyes | 4. Do your eyes: | |||
| a. Feel dry or gritty? | □ | □ | ||
| b. Have excessive tearing? | □ | □ | ||
| c. Hurt because of wind? | □ | □ | ||
| d. Have difficulty opening on waking? | □ | □ | ||
| 5. Do you use artificial tears? | □ | □ | □ ≤ 3× per day? or | |
| □ > 3× per day? | ||||
| 6. Have you had your tear ducts plugged or cauterized? | □ | □ | ||
| 7. Do you wear special eyewear or scleral lenses to relieve eye pain? | □ | □ | ||
| 8. Does your eye dryness affect your vision or prevent you from working? | □ | □ | ||
| Mouth | 9. Any mouth (or lip) sores or ulcers? | □ | □ | □ Using narcotics to relieve mouth symptoms? |
| □ Unable to eat because of pain? | ||||
| 10. Any discomfort with: | ||||
| a. Hot/cold? | □ | □ | ||
| b. Toothpaste? | □ | □ | ||
| c. Spicy food? | □ | □ | ||
| d. Soda/pop? | □ | □ | ||
| 11. Does your mouth feel dry most of the time? | □ | □ | ||
| 12. Is it difficult to open your mouth wide? | □ | □ | ||
| 13. Do mouth symptoms limit your oral intake? | □ | □ | □ Partially? □ In a major way? | |
| Sinuses | 14. Any draining of liquid into your throat? | □ | □ | |
| 15. Any sinus congestion or pain? | □ | □ | ||
| 16. Any recent sinus infections? | □ | □ | ||
| 17. Any sinus drainage surgery? | □ | □ | ||
| Gastrointestinal tract | 18. Do you have any of the following: | |||
| a. Nausea? | □ | □ | ||
| b. Vomiting? | □ | □ | ||
| c. Diarrhea? | □ | □ | ||
| d. Abdominal pain? | □ | □ | ||
| If no diarrhea, skip to question 20 | ||||
| 19. Did loose or liquid stools occur during the past week? | □ Some days? | |||
| □ Every day? | ||||
| □ Almost every day? | ||||
| □ Received intravenous or extra fluids during the past week to prevent or treat fluid loss from diarrhea? | ||||
| 20. Is your appetite: | ||||
| a. Poor or reduced from normal? | □ | □ | □ Are you easily full? | |
| b. Normal? | □ | □ | ||
| c. Increased? | □ | □ | ||
| 21. Did your lack of appetite, early fullness when eating, nausea or vomiting cause you to eat less during the past week? | □ Not applicable □ Occasionally last week? | |||
| □ Intermittently throughout the day? | ||||
| □ Persistent throughout the day? □ Almost every day last week? | ||||
| 22. How much do you normally weigh? | ________ lb/kg | |||
| 23. Have you had any recent weight loss? | □ | □ | □ How much weight loss divided by answer to question 22 × 100 = ___% loss?* | |
| 24. Is it painful to swallow? | □ | □ | ||
| 25. Do foods or pills get stuck? | □ | □ | ||
| 26. Can you easily swallow liquid/soft foods? | □ | □ | ||
| If no swallowing difficulties, skip to question 28 | ||||
| 27. During the past week swallowing difficulties occurred: | □ Occasionally? | |||
| □ Intermittently? | ||||
| □ Swallowing difficulties for almost everything on almost every day of the week these past 7 days? | ||||
| Musculoskeletal | 28. Are your arms, legs, or joints tight? | □ | □ | Affects activities of daily living: |
| □ Not at all? | ||||
| □ Moderately? | ||||
| □ Severely (unable to dress self, etc)? | ||||
| 29. Do you have muscle cramps or pains? | □ | □ | ||
| 30. Do you have muscle weakness? | □ | □ | ||
| 31. Do you have swollen feet, ankles, or joints? | □ | □ | ||
| Genitals | 32. Do you have vaginal (or penile, foreskin) dryness and/or discomfort during sexual activity or during a gynecologic examination? | □ | □ | Dryness/discomfort is: |
| □ Mild? | ||||
| □ Moderate? | ||||
| □ Severe? | ||||
| Lungs | 33. Do you get short of breath? | □ | □ | □ When at rest? |
| □ After 1 flight of stairs? | ||||
| □ When walking on flat? | ||||
| □ Using supplemental oxygen at any time? | ||||
| 34. Do you cough or wheeze? | □ | □ |
*