DVBCQSC2.m

DVBCQSC2 ;;ALB-CIOFO/ECF -  SCARS DISFIGUREMENT QUESTIONNAIRE ; 2/15/2011

 ;;2.7;AMIE;**172**;Apr 10, 1995;Build 3

 ;

TXT ;

 ;;

 ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for

 ;; disability benefits.  VA will consider the information you provide on this

 ;; questionnaire as part of their evaluation in processing the Veteran's claim.

 ;;

 ;; 1. Diagnosis

 ;;

 ;; a. Does the Veteran have one or more scars anywhere on the body, or

 ;; disfigurement of the head, face, or neck?

 ;; ___ Yes    ___ No

 ;;

 ;; If yes, provide only diagnoses that pertain to scars anywhere on the

 ;; body, or disfigurement of the head, face, or neck:

 ;;

 ;; Diagnosis #1: ____________________

 ;; ICD code: ________________________

 ;; Date of diagnosis: _______________

 ;;

 ;; Diagnosis #2: ____________________

 ;; ICD code: ________________________

 ;; Date of diagnosis: _______________

 ;;

 ;; Diagnosis #3: ____________________

 ;; ICD code:  _______________________

 ;; Date of diagnosis: _______________

 ;;

 ;; If there are additional diagnoses that pertain to scars anywhere on the

 ;; body, or disfigurement of the head, face, or neck due to scars or other

 ;; causes, list using above format: ___________________________________________

 ;;

 ;; b. Does the Veteran have any scars on the trunk or extremities (regions

 ;; other than the head, face or neck)?

 ;; ___ Yes    ___ No

 ;;

 ;; If yes, complete Section I

 ;;

 ;; c. Does the Veteran have any scars or disfigurement of the head, face

 ;; or neck?

 ;; ___ Yes    ___ No

 ;;

 ;; If yes, complete Section II

 ;;^TOF^

 ;; INSTRUCTIONS:

 ;; Provide all linear measurements in centimeters and area measurements in

 ;; centimeters squared.

 ;; For non-linear scars, measure the length and width at their widest points.

 ;; After measuring the scars, use the summary sections to

 ;; provide the combined approximate total area for all scars in each region.

 ;; If scars are too numerous to count (for example, multiple scattered shrapnel

 ;; wound scars, acne scarring or pseudofolliculitis barbae), indicate 'TNTC'

 ;; and provide approximate combined total area.

 ;;

 ;; Regardless of the answers to questions 1b and 1c, complete Section III.

 ;;

 ;; NOTE: For VA purposes, superficial non-linear scars are those not associated

 ;; with underlying soft tissue damage, while deep non-linear scars are

 ;; associated with underlying soft tissue damage.

 ;;

 ;; SECTION I:  Scars of the trunk and extremities

 ;;

 ;; 1. Medical history

 ;;

 ;; a. Describe the history (including cause/origin and course) of the Veteran's

 ;; scar(s) of the trunk or extremities, (brief summary): ______________________

 ;;

 ;; b. Are any of the scars of the trunk or extremities painful?

 ;; ___ Yes    ___ No

 ;; If yes, specify number of painful scars:

 ;;     __ 1   __ 2   __ 3   __ 4   __ 5 or more

 ;;     Describe the pain (if there are multiple painful scars, be sure to

 ;;     adequately identify which scars are painful): __________________________

 ;;

 ;; c. Are any of the scars of the trunk or extremities unstable, with frequent

 ;; loss of covering of skin over the scar?

 ;; ___ Yes    ___ No

 ;; If yes, specify number of unstable scars:

 ;;     __ 1   __ 2   __ 3   __ 4   __ 5 or more

 ;;     Describe the loss of covering of skin over the scar (if there are

 ;;     multiple unstable scars, be sure to adequately identify which scars are

 ;;     unstable): _____________________________________________________________

 ;;

 ;; d. Are any of the scars BOTH painful and unstable?

 ;; ___ Yes    ___ No

 ;; If yes, specify number of scars that are both painful and unstable:

 ;;     __ 1   __ 2   __ 3   __ 4   __ 5 or more

 ;;     Describe location of these scars: ______________________________________

 ;;^TOF^

 ;; e . Are any of the scars of the trunk or extremities due to burns?

 ;; ___ Yes    ___ No

 ;; If yes, identify each burn scar and state depth of original burn:

 ;; Burn Scar #1: _____________________

 ;;    ___ Full thickness or sub-dermal

 ;;    ___ Deep partial thickness

 ;;    ___ Less than deep partial thickness

 ;; Burn Scar #2: _____________________

 ;;    ___ Full thickness or sub-dermal

 ;;    ___ Deep partial thickness

 ;;    ___ Less than deep partial thickness

 ;;

 ;; If there are additional burn scars of the trunk and extremities, list using

 ;; the above format: __________________________________________________________

 ;;

 ;; 2. Physical exam for scars on the trunk and extremities

 ;;

 ;; 2-1. Details of scar findings for the trunk and extremities

 ;;

 ;; Indicate the anatomical regions affected and complete appropriate sections:

 ;;

 ;; a. Right upper extremity

 ;; ___ Affected    ___ Not affected

 ;;     Specify location of scars on right upper extremity and number them:

 ;;

 ;; ____________________________________________________________________________

 ;;

 ;;    Indicate types of scars and provide measurements (check all that apply):

 ;;

 ;;    ___ Linear

 ;;           Length of each linear scar:

 ;;           Scar #1: ___ cm   Scar #2: ___ cm

 ;;           Scar #3: ___ cm   Scar #4: ___ cm

 ;;           Scar #5: ___ cm

 ;;           If additional scars, list using same format:

 ;;           __________________________________________________________________

 ;;

 ;;    ___ Superficial non-linear

 ;;           Length and width of each superficial non-linear scar:

 ;;           Scar #1: ___x___ cm   Scar #2: ___x___ cm

 ;;           Scar #3: ___x___ cm   Scar #4: ___x___ cm

 ;;           Scar #5: ___x___ cm

 ;;           If additional scars, list using same format:

 ;;           __________________________________________________________________

 ;;^TOF^

 ;;    ___ Deep non-linear

 ;;           Length and width of each deep non-linear scar:

 ;;           Scar #1: ___x___ cm   Scar #2: ___x___ cm

 ;;           Scar #3: ___x___ cm   Scar #4: ___x___ cm   

 ;;           Scar #5: ___x___ cm

 ;;           If additional scars, list using same format:

 ;;           __________________________________________________________________

 ;;

 ;; b. Left upper extremity

 ;; ___ Affected    ___ Not affected

 ;;    Specify location of scars on left upper extremity and number them:

 ;;

 ;;  ___________________________________________________________________________

 ;;

 ;;    Indicate types of scars and provide measurements (check all that apply):

 ;;

 ;;    ___ Linear

 ;;           Length of each linear scar:

 ;;           Scar #1: ___ cm   Scar #2: ___ cm

 ;;           Scar #3: ___ cm   Scar #4: ___ cm

 ;;           Scar #5: ___ cm

 ;;           If additional scars, list using same format:

 ;;           __________________________________________________________________

 ;;

 ;;    ___ Superficial non-linear

 ;;           Length and width of each superficial non-linear scar:

 ;;           Scar #1: ___x___ cm   Scar #2: ___x___ cm

 ;;           Scar #3: ___x___ cm   Scar #4: ___x___ cm

 ;;           Scar #5: ___x___ cm

 ;;           If additional scars, list using same format:

 ;;           __________________________________________________________________

 ;;

 ;;    ___ Deep non-linear

 ;;           Length and width of each deep non-linear scar:

 ;;           Scar #1: ___x___ cm   Scar #2: ___x___ cm

 ;;           Scar #3: ___x___ cm   Scar #4: ___x___ cm

 ;;           Scar #5: ___x___ cm

 ;;           If additional scars, list using same format:

 ;;           __________________________________________________________________

 ;;^TOF^

 ;; c. Right lower extremity

 ;; ___ Affected    ___ Not affected

 ;;    Specify location of scars on right lower extremity and number them:

 ;;

 ;; ____________________________________________________________________________

 ;;

 ;;    Indicate types of scars and provide measurements (check all that apply):

 ;;

 ;;    ___ Linear

 ;;           Length of each linear scar:

 ;;           Scar #1: ___ cm   Scar #2: ___ cm

 ;;           Scar #3: ___ cm   Scar #4: ___ cm

 ;;           Scar #5: ___ cm

 ;;           If additional scars, list using same format:

 ;;           __________________________________________________________________

 ;;

 ;;    ___ Superficial non-linear

 ;;           Length and width of each superficial non-linear scar:

 ;;           Scar #1: ___x___ cm   Scar #2: ___x___ cm

 ;;           Scar #3: ___x___ cm   Scar #4: ___x___ cm

 ;;           Scar #5: ___x___ cm

 ;;           If additional scars, list using same format:

 ;;           __________________________________________________________________

 ;;

 ;;    ___ Deep non-linear

 ;;           Length and width of each deep non-linear scar:

 ;;           Scar #1: ___x___ cm   Scar #2: ___x___ cm

 ;;           Scar #3: ___x___ cm   Scar #4: ___x___ cm

 ;;           Scar #5: ___x___ cm

 ;;           If additional scars, list using same format:

 ;;           __________________________________________________________________

 ;;

 ;; d. Left lower extremity

 ;; ___ Affected    ___ Not affected

 ;;    Specify location of scars on left lower extremity and number them:

 ;;

 ;; ____________________________________________________________________________

 ;;

 ;;    Indicate types of scars and provide measurements (check all that apply):

 ;;

 ;;    ___ Linear

 ;;           Length of each linear scar:

 ;;           Scar #1: ___ cm   Scar #2: ___ cm

 ;;           Scar #3: ___ cm   Scar #4: ___ cm

 ;;           Scar #5: ___ cm

 ;;           If additional scars, list using same format:

 ;;           __________________________________________________________________

 ;;^TOF^

 ;;    ___ Superficial non-linear

 ;;           Length and width of each superficial non-linear scar:

 ;;           Scar #1: ___x___ cm   Scar #2: ___x___ cm

 ;;           Scar #3: ___x___ cm   Scar #4: ___x___ cm

 ;;           Scar #5: ___x___ cm

 ;;           If additional scars, list using same format:

 ;;           __________________________________________________________________

 ;;

 ;;    ___ Deep non-linear

 ;;           Length and width of each deep non-linear scar:

 ;;           Scar #1: ___x___ cm   Scar #2: ___x___ cm

 ;;           Scar #3: ___x___ cm   Scar #4: ___x___ cm

 ;;           Scar #5: ___x___ cm

 ;;           If additional scars, list using same format:

 ;;           __________________________________________________________________

 ;;

 ;; e. Anterior trunk

 ;; ___ Affected    ___ Not affected

 ;;    Specify location of scars on anterior trunk and number them:

 ;;

 ;;  ___________________________________________________________________________

 ;;

 ;;    Indicate types of scars and provide measurements (check all that apply):

 ;;

 ;;    ___ Linear

 ;;           Length of each linear scar:

 ;;           Scar #1: ___ cm   Scar #2: ___ cm

 ;;           Scar #3: ___ cm   Scar #4: ___ cm

 ;;           Scar #5: ___ cm

 ;;           If additional scars, list using same format:

 ;;           __________________________________________________________________

 ;;

 ;;    ___ Superficial non-linear

 ;;           Length and width of each superficial non-linear scar:

 ;;           Scar #1: ___x___ cm   Scar #2: ___x___ cm

 ;;           Scar #3: ___x___ cm   Scar #4: ___x___ cm

 ;;           Scar #5: ___x___ cm

 ;;           If additional scars, list using same format:

 ;;           __________________________________________________________________

 ;;

 ;;    ___ Deep non-linear

 ;;           Length and width of each deep non-linear scar:

 ;;           Scar #1: ___x___ cm   Scar #2: ___x___ cm

 ;;           Scar #3: ___x___ cm   Scar #4: ___x___ cm

 ;;           Scar #5: ___x___ cm

 ;;           If additional scars, list using same format:

 ;;           __________________________________________________________________

 ;;^TOF^

 ;; f. Posterior trunk

 ;; ___ Affected    ___ Not affected

 ;;    Specify location of scars on posterior trunk and number them:

 ;;

 ;; ____________________________________________________________________________

 ;;

 ;;    Indicate types of scars and provide measurements (check all that apply):

 ;;

 ;;    ___ Linear

 ;;           Length of each linear scar:

 ;;           Scar #1: ___ cm   Scar #2: ___ cm

 ;;           Scar #3: ___ cm   Scar #4: ___ cm

 ;;           Scar #5: ___ cm

 ;;           If additional scars, list using same format:

 ;;           __________________________________________________________________

 ;;

 ;;    ___ Superficial non-linear

 ;;           Length and width of each superficial non-linear scar:

 ;;           Scar #1: ___x___ cm   Scar #2: ___x___ cm

 ;;           Scar #3: ___x___ cm   Scar #4: ___x___ cm

 ;;           Scar #5: ___x___ cm

 ;;           If additional scars, list using same format:

 ;;           __________________________________________________________________

 ;;

 ;;    ___ Deep non-linear

 ;;          Length and width of each deep non-linear scar:

 ;;           Scar #1: ___x___ cm   Scar #2: ___x___ cm

 ;;           Scar #3: ___x___ cm   Scar #4: ___x___ cm

 ;;           Scar #5: ___x___ cm

 ;;           If additional scars, list using same format:

 ;;           __________________________________________________________________

 ;;

 ;; 2-2. Summary of nonlinear scar areas for the trunk and extremities

 ;;

 ;; a. Superficial non-linear scars (check all that apply and provide

 ;; approximate combined total area in centimeters squared for each affected

 ;; anatomical region)

 ;; ___ None

 ;; ___ Right upper extremity:    Approximate total area: ___________ cm2

 ;; ___ Left upper extremity:     Approximate total area: ___________ cm2

 ;; ___ Right lower extremity:    Approximate total area: ___________ cm2

 ;; ___ Left lower extremity:     Approximate total area: ___________ cm2

 ;; ___ Anterior trunk:           Approximate total area: ___________ cm2

 ;; ___ Posterior trunk:          Approximate total area: ___________ cm2

 ;;^TOF^

 ;; b. Deep non-linear scars (check all that apply and provide approximate

 ;; combined total area in centimeters squared for each affected anatomical

 ;; region)

 ;; ___ None

 ;; ___ Right upper extremity:    Approximate total area: ___________ cm2

 ;; ___ Left upper extremity:     Approximate total area: ___________ cm2

 ;; ___ Right lower extremity:    Approximate total area: ___________ cm2

 ;; ___ Left lower extremity:     Approximate total area: ___________ cm2

 ;; ___ Anterior trunk:           Approximate total area: ___________ cm2

 ;; ___ Posterior trunk:          Approximate total area: ___________ cm2

 Q

--- Routine Detail   --- with STRUCTURED ROUTINE LISTING ---DVBCQSC2   14797     printed  Apr 23, 2025@18:02:35                                                                                                                                                                                                   Page 2

DVBCQSC2  ;;ALB-CIOFO/ECF -  SCARS DISFIGUREMENT QUESTIONNAIRE ; 2/15/2011

 +1       ;;2.7;AMIE;**172**;Apr 10, 1995;Build 3

 +2       ;

TXT       ;

 +1       ;;

 +2       ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for

 +3       ;; disability benefits.  VA will consider the information you provide on this

 +4       ;; questionnaire as part of their evaluation in processing the Veteran's claim.

 +5       ;;

 +6       ;; 1. Diagnosis

 +7       ;;

 +8       ;; a. Does the Veteran have one or more scars anywhere on the body, or

 +9       ;; disfigurement of the head, face, or neck?

 +10      ;; ___ Yes    ___ No

 +11      ;;

 +12      ;; If yes, provide only diagnoses that pertain to scars anywhere on the

 +13      ;; body, or disfigurement of the head, face, or neck:

 +14      ;;

 +15      ;; Diagnosis #1: ____________________

 +16      ;; ICD code: ________________________

 +17      ;; Date of diagnosis: _______________

 +18      ;;

 +19      ;; Diagnosis #2: ____________________

 +20      ;; ICD code: ________________________

 +21      ;; Date of diagnosis: _______________

 +22      ;;

 +23      ;; Diagnosis #3: ____________________

 +24      ;; ICD code:  _______________________

 +25      ;; Date of diagnosis: _______________

 +26      ;;

 +27      ;; If there are additional diagnoses that pertain to scars anywhere on the

 +28      ;; body, or disfigurement of the head, face, or neck due to scars or other

 +29      ;; causes, list using above format: ___________________________________________

 +30      ;;

 +31      ;; b. Does the Veteran have any scars on the trunk or extremities (regions

 +32      ;; other than the head, face or neck)?

 +33      ;; ___ Yes    ___ No

 +34      ;;

 +35      ;; If yes, complete Section I

 +36      ;;

 +37      ;; c. Does the Veteran have any scars or disfigurement of the head, face

 +38      ;; or neck?

 +39      ;; ___ Yes    ___ No

 +40      ;;

 +41      ;; If yes, complete Section II

 +42      ;;^TOF^

 +43      ;; INSTRUCTIONS:

 +44      ;; Provide all linear measurements in centimeters and area measurements in

 +45      ;; centimeters squared.

 +46      ;; For non-linear scars, measure the length and width at their widest points.

 +47      ;; After measuring the scars, use the summary sections to

 +48      ;; provide the combined approximate total area for all scars in each region.

 +49      ;; If scars are too numerous to count (for example, multiple scattered shrapnel

 +50      ;; wound scars, acne scarring or pseudofolliculitis barbae), indicate 'TNTC'

 +51      ;; and provide approximate combined total area.

 +52      ;;

 +53      ;; Regardless of the answers to questions 1b and 1c, complete Section III.

 +54      ;;

 +55      ;; NOTE: For VA purposes, superficial non-linear scars are those not associated

 +56      ;; with underlying soft tissue damage, while deep non-linear scars are

 +57      ;; associated with underlying soft tissue damage.

 +58      ;;

 +59      ;; SECTION I:  Scars of the trunk and extremities

 +60      ;;

 +61      ;; 1. Medical history

 +62      ;;

 +63      ;; a. Describe the history (including cause/origin and course) of the Veteran's

 +64      ;; scar(s) of the trunk or extremities, (brief summary): ______________________

 +65      ;;

 +66      ;; b. Are any of the scars of the trunk or extremities painful?

 +67      ;; ___ Yes    ___ No

 +68      ;; If yes, specify number of painful scars:

 +69      ;;     __ 1   __ 2   __ 3   __ 4   __ 5 or more

 +70      ;;     Describe the pain (if there are multiple painful scars, be sure to

 +71      ;;     adequately identify which scars are painful): __________________________

 +72      ;;

 +73      ;; c. Are any of the scars of the trunk or extremities unstable, with frequent

 +74      ;; loss of covering of skin over the scar?

 +75      ;; ___ Yes    ___ No

 +76      ;; If yes, specify number of unstable scars:

 +77      ;;     __ 1   __ 2   __ 3   __ 4   __ 5 or more

 +78      ;;     Describe the loss of covering of skin over the scar (if there are

 +79      ;;     multiple unstable scars, be sure to adequately identify which scars are

 +80      ;;     unstable): _____________________________________________________________

 +81      ;;

 +82      ;; d. Are any of the scars BOTH painful and unstable?

 +83      ;; ___ Yes    ___ No

 +84      ;; If yes, specify number of scars that are both painful and unstable:

 +85      ;;     __ 1   __ 2   __ 3   __ 4   __ 5 or more

 +86      ;;     Describe location of these scars: ______________________________________

 +87      ;;^TOF^

 +88      ;; e . Are any of the scars of the trunk or extremities due to burns?

 +89      ;; ___ Yes    ___ No

 +90      ;; If yes, identify each burn scar and state depth of original burn:

 +91      ;; Burn Scar #1: _____________________

 +92      ;;    ___ Full thickness or sub-dermal

 +93      ;;    ___ Deep partial thickness

 +94      ;;    ___ Less than deep partial thickness

 +95      ;; Burn Scar #2: _____________________

 +96      ;;    ___ Full thickness or sub-dermal

 +97      ;;    ___ Deep partial thickness

 +98      ;;    ___ Less than deep partial thickness

 +99      ;;

 +100     ;; If there are additional burn scars of the trunk and extremities, list using

 +101     ;; the above format: __________________________________________________________

 +102     ;;

 +103     ;; 2. Physical exam for scars on the trunk and extremities

 +104     ;;

 +105     ;; 2-1. Details of scar findings for the trunk and extremities

 +106     ;;

 +107     ;; Indicate the anatomical regions affected and complete appropriate sections:

 +108     ;;

 +109     ;; a. Right upper extremity

 +110     ;; ___ Affected    ___ Not affected

 +111     ;;     Specify location of scars on right upper extremity and number them:

 +112     ;;

 +113     ;; ____________________________________________________________________________

 +114     ;;

 +115     ;;    Indicate types of scars and provide measurements (check all that apply):

 +116     ;;

 +117     ;;    ___ Linear

 +118     ;;           Length of each linear scar:

 +119     ;;           Scar #1: ___ cm   Scar #2: ___ cm

 +120     ;;           Scar #3: ___ cm   Scar #4: ___ cm

 +121     ;;           Scar #5: ___ cm

 +122     ;;           If additional scars, list using same format:

 +123     ;;           __________________________________________________________________

 +124     ;;

 +125     ;;    ___ Superficial non-linear

 +126     ;;           Length and width of each superficial non-linear scar:

 +127     ;;           Scar #1: ___x___ cm   Scar #2: ___x___ cm

 +128     ;;           Scar #3: ___x___ cm   Scar #4: ___x___ cm

 +129     ;;           Scar #5: ___x___ cm

 +130     ;;           If additional scars, list using same format:

 +131     ;;           __________________________________________________________________

 +132     ;;^TOF^

 +133     ;;    ___ Deep non-linear

 +134     ;;           Length and width of each deep non-linear scar:

 +135     ;;           Scar #1: ___x___ cm   Scar #2: ___x___ cm

 +136     ;;           Scar #3: ___x___ cm   Scar #4: ___x___ cm   

 +137     ;;           Scar #5: ___x___ cm

 +138     ;;           If additional scars, list using same format:

 +139     ;;           __________________________________________________________________

 +140     ;;

 +141     ;; b. Left upper extremity

 +142     ;; ___ Affected    ___ Not affected

 +143     ;;    Specify location of scars on left upper extremity and number them:

 +144     ;;

 +145     ;;  ___________________________________________________________________________

 +146     ;;

 +147     ;;    Indicate types of scars and provide measurements (check all that apply):

 +148     ;;

 +149     ;;    ___ Linear

 +150     ;;           Length of each linear scar:

 +151     ;;           Scar #1: ___ cm   Scar #2: ___ cm

 +152     ;;           Scar #3: ___ cm   Scar #4: ___ cm

 +153     ;;           Scar #5: ___ cm

 +154     ;;           If additional scars, list using same format:

 +155     ;;           __________________________________________________________________

 +156     ;;

 +157     ;;    ___ Superficial non-linear

 +158     ;;           Length and width of each superficial non-linear scar:

 +159     ;;           Scar #1: ___x___ cm   Scar #2: ___x___ cm

 +160     ;;           Scar #3: ___x___ cm   Scar #4: ___x___ cm

 +161     ;;           Scar #5: ___x___ cm

 +162     ;;           If additional scars, list using same format:

 +163     ;;           __________________________________________________________________

 +164     ;;

 +165     ;;    ___ Deep non-linear

 +166     ;;           Length and width of each deep non-linear scar:

 +167     ;;           Scar #1: ___x___ cm   Scar #2: ___x___ cm

 +168     ;;           Scar #3: ___x___ cm   Scar #4: ___x___ cm

 +169     ;;           Scar #5: ___x___ cm

 +170     ;;           If additional scars, list using same format:

 +171     ;;           __________________________________________________________________

 +172     ;;^TOF^

 +173     ;; c. Right lower extremity

 +174     ;; ___ Affected    ___ Not affected

 +175     ;;    Specify location of scars on right lower extremity and number them:

 +176     ;;

 +177     ;; ____________________________________________________________________________

 +178     ;;

 +179     ;;    Indicate types of scars and provide measurements (check all that apply):

 +180     ;;

 +181     ;;    ___ Linear

 +182     ;;           Length of each linear scar:

 +183     ;;           Scar #1: ___ cm   Scar #2: ___ cm

 +184     ;;           Scar #3: ___ cm   Scar #4: ___ cm

 +185     ;;           Scar #5: ___ cm

 +186     ;;           If additional scars, list using same format:

 +187     ;;           __________________________________________________________________

 +188     ;;

 +189     ;;    ___ Superficial non-linear

 +190     ;;           Length and width of each superficial non-linear scar:

 +191     ;;           Scar #1: ___x___ cm   Scar #2: ___x___ cm

 +192     ;;           Scar #3: ___x___ cm   Scar #4: ___x___ cm

 +193     ;;           Scar #5: ___x___ cm

 +194     ;;           If additional scars, list using same format:

 +195     ;;           __________________________________________________________________

 +196     ;;

 +197     ;;    ___ Deep non-linear

 +198     ;;           Length and width of each deep non-linear scar:

 +199     ;;           Scar #1: ___x___ cm   Scar #2: ___x___ cm

 +200     ;;           Scar #3: ___x___ cm   Scar #4: ___x___ cm

 +201     ;;           Scar #5: ___x___ cm

 +202     ;;           If additional scars, list using same format:

 +203     ;;           __________________________________________________________________

 +204     ;;

 +205     ;; d. Left lower extremity

 +206     ;; ___ Affected    ___ Not affected

 +207     ;;    Specify location of scars on left lower extremity and number them:

 +208     ;;

 +209     ;; ____________________________________________________________________________

 +210     ;;

 +211     ;;    Indicate types of scars and provide measurements (check all that apply):

 +212     ;;

 +213     ;;    ___ Linear

 +214     ;;           Length of each linear scar:

 +215     ;;           Scar #1: ___ cm   Scar #2: ___ cm

 +216     ;;           Scar #3: ___ cm   Scar #4: ___ cm

 +217     ;;           Scar #5: ___ cm

 +218     ;;           If additional scars, list using same format:

 +219     ;;           __________________________________________________________________

 +220     ;;^TOF^

 +221     ;;    ___ Superficial non-linear

 +222     ;;           Length and width of each superficial non-linear scar:

 +223     ;;           Scar #1: ___x___ cm   Scar #2: ___x___ cm

 +224     ;;           Scar #3: ___x___ cm   Scar #4: ___x___ cm

 +225     ;;           Scar #5: ___x___ cm

 +226     ;;           If additional scars, list using same format:

 +227     ;;           __________________________________________________________________

 +228     ;;

 +229     ;;    ___ Deep non-linear

 +230     ;;           Length and width of each deep non-linear scar:

 +231     ;;           Scar #1: ___x___ cm   Scar #2: ___x___ cm

 +232     ;;           Scar #3: ___x___ cm   Scar #4: ___x___ cm

 +233     ;;           Scar #5: ___x___ cm

 +234     ;;           If additional scars, list using same format:

 +235     ;;           __________________________________________________________________

 +236     ;;

 +237     ;; e. Anterior trunk

 +238     ;; ___ Affected    ___ Not affected

 +239     ;;    Specify location of scars on anterior trunk and number them:

 +240     ;;

 +241     ;;  ___________________________________________________________________________

 +242     ;;

 +243     ;;    Indicate types of scars and provide measurements (check all that apply):

 +244     ;;

 +245     ;;    ___ Linear

 +246     ;;           Length of each linear scar:

 +247     ;;           Scar #1: ___ cm   Scar #2: ___ cm

 +248     ;;           Scar #3: ___ cm   Scar #4: ___ cm

 +249     ;;           Scar #5: ___ cm

 +250     ;;           If additional scars, list using same format:

 +251     ;;           __________________________________________________________________

 +252     ;;

 +253     ;;    ___ Superficial non-linear

 +254     ;;           Length and width of each superficial non-linear scar:

 +255     ;;           Scar #1: ___x___ cm   Scar #2: ___x___ cm

 +256     ;;           Scar #3: ___x___ cm   Scar #4: ___x___ cm

 +257     ;;           Scar #5: ___x___ cm

 +258     ;;           If additional scars, list using same format:

 +259     ;;           __________________________________________________________________

 +260     ;;

 +261     ;;    ___ Deep non-linear

 +262     ;;           Length and width of each deep non-linear scar:

 +263     ;;           Scar #1: ___x___ cm   Scar #2: ___x___ cm

 +264     ;;           Scar #3: ___x___ cm   Scar #4: ___x___ cm

 +265     ;;           Scar #5: ___x___ cm

 +266     ;;           If additional scars, list using same format:

 +267     ;;           __________________________________________________________________

 +268     ;;^TOF^

 +269     ;; f. Posterior trunk

 +270     ;; ___ Affected    ___ Not affected

 +271     ;;    Specify location of scars on posterior trunk and number them:

 +272     ;;

 +273     ;; ____________________________________________________________________________

 +274     ;;

 +275     ;;    Indicate types of scars and provide measurements (check all that apply):

 +276     ;;

 +277     ;;    ___ Linear

 +278     ;;           Length of each linear scar:

 +279     ;;           Scar #1: ___ cm   Scar #2: ___ cm

 +280     ;;           Scar #3: ___ cm   Scar #4: ___ cm

 +281     ;;           Scar #5: ___ cm

 +282     ;;           If additional scars, list using same format:

 +283     ;;           __________________________________________________________________

 +284     ;;

 +285     ;;    ___ Superficial non-linear

 +286     ;;           Length and width of each superficial non-linear scar:

 +287     ;;           Scar #1: ___x___ cm   Scar #2: ___x___ cm

 +288     ;;           Scar #3: ___x___ cm   Scar #4: ___x___ cm

 +289     ;;           Scar #5: ___x___ cm

 +290     ;;           If additional scars, list using same format:

 +291     ;;           __________________________________________________________________

 +292     ;;

 +293     ;;    ___ Deep non-linear

 +294     ;;          Length and width of each deep non-linear scar:

 +295     ;;           Scar #1: ___x___ cm   Scar #2: ___x___ cm

 +296     ;;           Scar #3: ___x___ cm   Scar #4: ___x___ cm

 +297     ;;           Scar #5: ___x___ cm

 +298     ;;           If additional scars, list using same format:

 +299     ;;           __________________________________________________________________

 +300     ;;

 +301     ;; 2-2. Summary of nonlinear scar areas for the trunk and extremities

 +302     ;;

 +303     ;; a. Superficial non-linear scars (check all that apply and provide

 +304     ;; approximate combined total area in centimeters squared for each affected

 +305     ;; anatomical region)

 +306     ;; ___ None

 +307     ;; ___ Right upper extremity:    Approximate total area: ___________ cm2

 +308     ;; ___ Left upper extremity:     Approximate total area: ___________ cm2

 +309     ;; ___ Right lower extremity:    Approximate total area: ___________ cm2

 +310     ;; ___ Left lower extremity:     Approximate total area: ___________ cm2

 +311     ;; ___ Anterior trunk:           Approximate total area: ___________ cm2

 +312     ;; ___ Posterior trunk:          Approximate total area: ___________ cm2

 +313     ;;^TOF^

 +314     ;; b. Deep non-linear scars (check all that apply and provide approximate

 +315     ;; combined total area in centimeters squared for each affected anatomical

 +316     ;; region)

 +317     ;; ___ None

 +318     ;; ___ Right upper extremity:    Approximate total area: ___________ cm2

 +319     ;; ___ Left upper extremity:     Approximate total area: ___________ cm2

 +320     ;; ___ Right lower extremity:    Approximate total area: ___________ cm2

 +321     ;; ___ Left lower extremity:     Approximate total area: ___________ cm2

 +322     ;; ___ Anterior trunk:           Approximate total area: ___________ cm2

 +323     ;; ___ Posterior trunk:          Approximate total area: ___________ cm2

 +324      QUIT