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Chronic GVHD Screening (NM800080)

Chronic GVHD Screening (NM800080) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires



Patient Name

DOB:

MR #




NM800080 (Rev.09/26/16) Worksheet Only – Not a Medical Record Document

UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
CHRONIC GVHD (Graft-Versus-Host Disease)
SCREENING



Screening Timing
□ Pretransplant (baseline)
□ Post-transplant
Overall, compared to last visit, how are you feeling
□ Better
□ Worse
□ The Same

Do you have any of the following skin problems?
□ Tightness or hardness
□ Increased dryness
□ Itchiness
□ New rashes or changes in your skin color
□ Inability to sweat or keep your body warm

Have you had any recent loss of scalp or body hair or nail changes?
□ Loss of hair
□ Nail changes

In your wrists, fingers, or other joints, do you have any of the following?
□ Stiffness
□ Pain

Do you have any of the following eye problems?
□ Dryness
□ Sensitivity to wind or air conditioning
□ Feelings of pain or grittiness

Do you have any of the following mouth problems?
□ Dryness
□ Sensitivity to hot or cold temperatures or strong flavors
□ Ulcers or sores
□ Changes in taste
□ Food or pills get stuck while swallowing




Patient Name

DOB:

MR #




NM800080 (Rev.09/26/16) Worksheet Only – Not a Medical Record Document

UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
CHRONIC GVHD (Graft-Versus-Host Disease)
SCREENING




Do you have shortness of breath in either of the following situations?
□ At rest
□ With activity

Do you have any of the following breathing problems?
□ Coughing
□ Wheezing

Have you noticed an of the following problems?
Females:
□ Discomfort or pain with sexual intercourse
□ Vaginal dryness or itching

Males:
□ Burning or difficulty with urination
□ Genital pain

Do you have any of the following problem with your weight?
□ Unexplained weight loss
□ Inability to gain weight












Tool Approved: 9/1/2016
Questions adapted from Fred Hutchinson screening questions
Flowers ME, Martin PJ. How we treat chronic graft-versus-host disease. Blood. 2015; 125(4): 606-615.