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 ---[H[J[2J[HDVBCQSC2 14797 printed Nov 22, 2024@16:58:18 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
