Page 130 - When surgery alone won’t cut it - Valerie Maureen Monpellier

Chapter 7
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score.
1. Because of the excess skin I suffer of (please tick all that apply):
Skin condition
How often do you have these complaints
Always
Sometimes
never
Dermatitis
intertrigo
Infection
Ulceration
Lymphoedema
Hidradenitis
2. The excess skin causes problems in:
 Daily routine (like showering and getting dressed), at work and during
physical activity
 Only during physical activity
 Never
3. The excess skin causes of worsens psychological issues (like fear, depression, sleep disturbance, stress):
 Always
 Sometimes
 Never
4. Have you had changes in your weight fluctuations in the last 12 months?
 No
 0 – 5 kilograms
 5 – 10 kilograms
 10 – 20 kilograms
 More than 20 kilograms
5. Do you smoke or have you ever smoked?
 Yes, but I have quite (go on to question number 6)
 Yes, and I still smoke (go on to question number 8)
 No (go on to question number 9)
6. When did you stop smoking? ...............................
7. What was the most you ever smoked?
 Very rarely
 Socially (less than 2 cigarettes per week)
 less than 5 cigarettes per day
 5-10 cigarettes per day
 11-20 cigarettes per day
 21-40 cigarettes per day
 More than 40 cigarettes per day
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