---

Home | Contact us | Research Info

---

EVALUATOR INFORMATION

Name: ______________________________________________________________

Degree: ____________ Specialty: _______________________________________

Date: ________________

SUBJECT INFORMATION

Name of Patient:_______________________________________________________

Accession Number ____________ (will be filled in by lab))

Family: _______________________________________________

HISTORICAL INFORMATION (to be obtained by evaluator:)

Current Age _________ Sex _________ Race __________________

Does the subject believe he/she currently has, or has ever had, psoriasis?

Yes No If yes, age of onset (by history) __________

Does the subject carry a prior diagnosis of psoriasis?

Yes No If yes, age at first diagnosis _____________

Biological Parents' names: Father _____________________ Mother___________________

CLINICAL EVALUATION (to be filled out by evaluator)

1. Psoriasis Area and Severity Index (PASI )Scoring

Score % total body surface area (TBSA) as follows: 1% TBSA is approximately the area of the palm of the hand (exclusive of fingers and thumb).
Score erythema, desquamation, infiltration, and pustules as follows: 0 = absent; 6 = severe.

Body site (% of total body surface area)	%TBSA involved with psoriasis	Erythema (Redness)	Desquamation (peeling or scaling)	Infiltration (firmness to touch)	Pustlues
Head (9% of TBSA
Trunk/Back (36%)
Upper ext. (18%)
Lower ext. (36%)

2. Total Body Surface Area (add values in column 2) _________________%

3. Nail Involvement

Finding	# fingernails involved	# toe nails involved
Pits (depressions in nail plate)
Onycholysis (separation of nail plate from nail bed)
Oil-drop change (yellowish discoloration of nail)

4. Scalp Involvement

a. _____% of TBSA (one palm = 1% TBSA)

b. Alopecia (hair loss)? (Y / N) _______

c. Androgenetic pattern of hair loss (male pattern baldness)? (Y / N) _______

d. Hamilton grade (I-V) _________

5. Joint Involvement

	# joints	body site(s)
Symptomatic, but non-deforming
Deforming

6. Photograph

Please photograph involved areas from all affected individuals, if a camera is available.

Exposure numbers	Sites photographed

7. Blood Drawing:

a. Draw blood into green-top (heparinized) vacutainer tubes (30 cc per person, no more than 10% of blood volume for small children.
b. Mix well by inverting. Samples should be left at room temperature, do not refrigerate.

OVERALL IMPRESSION (to be completed by dermatologists only)

a. Please rank from 1 to 4 the clinical form(s) of psoriasis that best describe this patient:

Chronic Plaque _________________________ Pustular _________________________

Guttate _________________________ Palmoplantar _________________________

Scalp _________________________ Erythrodermic _________________________

Flexural (inverse) _________ Psoriatic arthritis _________

Other _______________________________________

If "other", please specify type:

b. Please circle the category of psoriasis that you believe best describes this individual:

Category	Description
Definite	two or more definite clinical findings
Equivocal	morphologically suggestive (could be seborrheic dermatitis, eczema, lupus, mycosis fungoides, tinea)
Probable	no psoriasis now, but previously diagnosed by a dermatologist with records available for review
Possible	patient believes he/she has had psoriasis, no evidence of it now, not diagnosed by a dermatologist in the past
No psoriasis	patient believes he/she has never had psoriasis, absence of psoriasis confirmed by exam
No information	use this category if patient has not been examined, whether or not blood has been drawn

c. Overall, do you believe that the patient has psoriasis? Yes No