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Приложение

Амбулаторная карта пациента с гнёздной алопецией №___

1.1 Ф.И.О.

__________________________________________________________________________

1.5Пол Муж. Жен.

1.6Расовая принадлежность:

220

3.Анамнез гнездной алопеции:

3.1Количество предшествующих эпизодов гнездного облысения_____________________

3.2Возраст в момент начала 1-го эпизода гнездного облысения___________________

3.3Первый эпизод гнездного облысения (месяц/год начала)_________________________

3.4Анамнез тотальной формы или тотальной/универсальной формы ГА, возникавшей в какое-либо время:

3.4.1продолжительностью >2 лет______________________________________________

3.4.2 продолжительностью ≤2 лет______________________________________________

3.5 Текущий эпизод гнездного облысения:

3.5.3.312–24 мес

4. Соответствующий анамнез инфекций, имевших место в ближайшие 6 месяцев перед началом потери волос:

4.1Локализация инфекции перед первоначальным эпизодом гнездного облысения

__________________________________________________________________________

4.1.1Вид инфекции________________________________________________________

4.2Локализация инфекции перед текущим эпизодом гнездного облысения

____________________________________________________________________________

4.2.1 Вид инфекции _________________________________________________________

5. Анамнез вакцинаций в ближайшие 6 мес перед началом потери волос

5.1Вид вакцинации перед первоначальным эпизодом гнездного облысения

___________________________________________________________________________

5.2Вид вакцинации перед текущим эпизодом гнездного облысения

_________________________________________________________________________

6.Мнение пациента или родителя пациента в отношении пускового фактора потери волос

6.1Первоначальный эпизод__________________________________________________

6.2Текущий эпизод _________________________________________________________

7.Характер потери волос на скальпе:

3.3.1Локальный (в т.ч. субтотальная форма),

3.3.2Краевое гнездное облысение (офиаз),

3.3.3Тотальный (потеря 100 % волос скальпа).

3.3.4Универсальный

3.3.5Диффузый

8.Оценка распространённости алопеции до лечения.

8.1 Показатель тяжести алопеции (в %) _____________________________