Generic Skin Care Questionnaire And Assessment
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Generic Skin Care Questionnaire and Assessment
This questionnaire is to be completed in conjunction with a visual assessment of the HCWs hands by
the ICP, staff health nurse or HH program co-ordinator. Where possible the assessment should be
completed after at least 1-2 days at work not immediately after days off.
Name:
Date initial visit:
Employee No.:
Occupation:
Work Phone:
Number of days last
worked consecutively:
Mobile:
Email:
Ward/Dept:
Campus:
Skin Assessment
Please organise photographs of both hands and all surfaces (include “close ups” of inflamed areas).
Repeat if condition worsens. Photographs must be dated and signed.
Redness
0
1
2
3
Please circle most
no redness
small area of redness
moderate redness
severe redness
appropriate
limited to sensitive
to include the
which includes all
areas
cuticles and
areas
i.e. around cuticles
knuckles
Swelling
0
1
2
3
Please circle most
no swelling
mild swelling around
moderate swelling
severe swelling
appropriate
cuticles only
all areas
Rash
0
1
2
3
Please circle most
no rash
mild rash, a few small
moderate finger
severe all areas
appropriate
eruptions only
and palm area
of hands dry and
involved
rough to touch
Dryness/cracking
0
1
2
3
Please circle most
intact skin
mild dryness/cracking,
moderate finger
severe involving
appropriate
around cuticles and
and palm area
all areas of hands
knuckles
involved
Total Score:
(refer to flow chart for management):
Comments:
Review Date:
Document reviewed Nov 2012
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