A study in conjunction with The British Paediatric Surveillance Unit of the Royal College of Paediatrics and
Child Health
December 2004
CHILDHOOD SCLERODERMA
12-MONTH FOLLOW-UP QUESTIONNAIRE
Study Number:
To be completed by investigator
Hospital:
Form completed by:
Patient’s initials:
Date of Birth:
Post code
(first 3 letters)
A study in conjunction with The British Paediatric Surveillance Unit of the Royal College of Paediatrics and
Child Health
December 2004
1. Has the diagnosis changed since initial
Yes
No
form (enclosed) completed?
2. Has the diagnosis been confirmed by a
Yes
No
dermatologist or a rheumatologist?
If yes (please tick which one)
Dermatologist
Rheumatologist
3. What was the “result” from the specialist opinion. For example did the specialist opinion
confirm or refute the initial diagnosis?
Please comment:
4. Has the condition
a. Resolved
Yes
No
b. Improved
Yes
No
c. Deteriorated
Yes
No
5. Is the child still alive?
Yes
No
If no cause of death
Date of death
Month
Year
6. Any significant changes in
a. Symptoms
Yes
No
If yes please comment
A study in conjunction with The British Paediatric Surveillance Unit of the Royal College of Paediatrics and
Child Health
December 2004
b. Signs
Yes
No
If yes please comment
7. Any clinically significant results from
Yes
No
investigations?
If yes please comment
8. Treatments initiated in past 12 months
Initiated
Continuing
Name of drug
Yes No Yes
No (if no please state reason for stopping)
Oral steroids
Parental steroids
Methotrexate
Cyclophosphamide ORAL
Cyclophosphamide I.V.
D-Penicillamine
Prostanoids
Calcium channel blockers
AC