Name:

Phone number:

Initial Questions

How long have you been suffering from itchy skin?

Which parts of your body are itchy?

Circle which of the following you have tried:

☐ Topical steroids (eg: hydrocortisone, triamcinolone)
☐ Anti-histamines (eg: Benadryl, Allegra, Zyrtec, Atarax, Claritin)
☐ Prednisone/ Oral steroids
☐ Phototherapy
☐ Other:

How would you rate your WORST itch in the past 24 hours, on a scale from 0 to 10, where 0 is No Itch and 10 is Worst Itch Imaginable:

☐ 0      ☐ 1      ☐ 2      ☐ 3      ☐ 4      ☐ 5      ☐ 6      ☐ 7      ☐ 8      ☐ 9      ☐ 10 

5-D Pruritus Scale

1. Duration: During the last 2 weeks, how many hours a day have you been itching?

☐ Less than 6 hrs/day    ☐ 6 – 12 hrs/day    ☐ 12 – 18 hrs/day    ☐ 18 – 23 hrs/day    ☐ All day

2. Degree: Please rate the intensity of your itching over the past 2 weeks

☐ Not Present    ☐ Mild    ☐ Moderate    ☐ Severe    ☐ Unbearable

3. Direction: Over the past 2 weeks has your itching gotten better or worse compared to the previous month?

☐ Completely    ☐ Much better, but    ☐ Little bit better,   ☐ Unchanged    ☐ Getting worse
       resolved              still present            but still present 

4. Disability: Rate the impact of your itching on the following activities over the last 2 weeks

Sleep
☐ Never affects   ☐ Occasionally   ☐ Frequently        ☐ Delays falling        ☐ Delays falling asleep &
            sleep            delays falling      delays falling   asleep & occasionally   frequently wakes me up
                                       asleep                asleep          wakes me up at night                at night

Leisure/Social
☐ N/A   ☐ Never affects   ☐ Rarely affects   ☐ Occasionally affects    ☐ Frequently     ☐ Always
                   this activity           this activity                this activity               affects this    affects this
                                                                                                                           activity          activity

Housework/Errands
☐ N/A   ☐ Never affects   ☐ Rarely affects   ☐ Occasionally affects    ☐ Frequently     ☐ Always
                   this activity           this activity                this activity               affects this    affects this
                                                                                                                           activity          activity

Work/School
☐ N/A   ☐ Never affects   ☐ Rarely affects   ☐ Occasionally affects    ☐ Frequently     ☐ Always
                   this activity           this activity                this activity               affects this    affects this
                                                                                                                           activity          activity

5. Distribution: Mark whether itching has been present in the following parts of your body over the last 2 weeks.  If a body part is not listed, choose the one that is closest anatomically.

Head/Scap ☐ Soles ☐
Face ☐ Palms ☐
Chest ☐ Tops of Hands/Fingers ☐
Abdomen ☐ Forearms ☐
Back ☐ Upper arms ☐
Buttocks ☐ Points of Contact w/ Clothing ☐
Things ☐ (eg. Waistband, undergarment) ☐
Tower legs ☐ Groin ☐
Tops of Feet ☐ Toes ☐

Physicians Complete

1. MRN:

2. Current Medications:

3. PMH of Atopic dermatitis?

4. PMH of asthma or hay fever?

5. PMH of systemic disease associated with pruritus?

Disorders of iron metabolism (eg: iron deficiency, vegan diet)
Hepatic disease (especially cholestasis)
Uremia/ESRD/CKD/Dialysis Patient
Hematological Disorder (eg: polycythemia vera)
Malignancy/Cancers
Recent infection (eg: scabies, bed bugs)
Psychological and emotional factors
Adverse drug reactins (opioid, chloroquine)

6. Any new medications within 3 months of the itch starting?

7. Labs

Serum IgE
Peripheral Eosinophil Count

8. Physical Examination

Clinical Exam:  (eg: xerosis, excoriations, excoriated papules)
Is there dermatographism?

9. Is there evidence of prurigo nodularis?

Recommended Work-up for Generalized Idiopathic Pruritus

Visit 1

☐ Careful ROS (fever, night sweats, weight loss)
☐ Careful review of PMH, specifically disorders associated with pruritus:

Disorders of iron metabolism (eg: iron deficiency, vegan diet)
Hepatic disease (especially cholestasis)
Uremia/ESRD/CKD/Dialysis Patient
Hematological Disorder (eg: polycythemia vera)
Malignancy/Cancers
Recent infection (eg: scabies)
Psychological and emotional factors
Adverse drug reactins (opioid, chloroquine)

☐ Careful review of medications (ACEI, new medications, opioids, chloroquine)
☐ Careful physical exam

Dermatographism
Lymphadenopathy
Hepatosplenomegaly

☐ Labs

CBC, CMP
Consider IgE (especially if +dermatographism)

☐ CXR
☐ Switch ACE Inhibitor
☐ Permethrin or ivermectin

Visit 2

☐ 2 punch biopsies:  DIF, H/E
☐ Consider BP Serologies in addition to (but not instead of) tissue biopsy because of high false-positive rate