SAINT LOUIS UNIVERSITY DEPARTMENT OF DERMATOLOGY Division of Cosmetic & Laser Surgery Hyperhidrosis Evaluation Form Des Peres Medical Arts Pavilion 2315 Dougherty Ferry Road, Suite 200 Today’s Date (mm/dd/yy): _____ / _____ / _____ St. Louis, MO 63122 Name: ______(314) 977-9666 Date of Birth (mm/dd/yy): _____ / _____ / _____ Age: ______E-mail address, if interested in receiving email about hyperhidrosis opportunities: ______

Please complete the following to the best of your knowledge:

1. Ethnicity (check box): 2. Please check your main concern with today’s visit: White African-American Excessive Sweating or Hispanic American Indian Body Odor Asian Other, specify:______Other, specify:______

3. Select the area(s) that has the worst sweating: 4. Other areas that also have a sweating problem: Axilla/ Underarms Axilla/Underarms Hands/ Palms Hands/ Palms Feet/ Soles Face or scalp Feet/Soles Face or scalp Groin Other, specify: ______Groin Other, specify: ______

5. Is the sweating problem on both sides of your body? 6. Factors that worsen or trigger the sweating problem: YES Stress Heat Pregnancy NO : RIGHT side sweats much more or Anxiety Sleep Menstrual cycle LEFT side sweats much more Exercise Cold Other, specify:______

7. Factors that improve sweating (list): ______

8. Do your sweating symptoms stop while you sleep? Yes No Other: ______

9. Age when the sweating problem first began: ______years old If unsure, estimate age range: 0 – 12 yrs 13 – 25 yrs 26 – 40 yrs >40 yrs

10. Have you had skin problems related to excessive sweating? Macerated/peeling skin Bacterial infections Fungal infections Blisters Other: ______None

11. If you have ever been pregnant, how did this affect your sweating? Not applicable Remained the same Sweating improved during pregnancy Sweating worsened during pregnancy

12. Which is your dominant hand? RIGHT-handed LEFT-handed BOTH- handed

13. Do you have any relatives affected by excessive sweating? (check the box below) YES – a relative has excessive sweating If yes, please indicate their relationship to you: ______Check the area(s) of your relative’s sweating: axillary/underarm face feet/soles hand/palm groin other______NO – No one else in my family has excessive sweating UNKNOWN – Don’t know

Page 1 of 4 version 10/9/12 14. Have you seen someone about this problem in the past (check all that apply)? YES, please indicate who you saw: Pediatrician Primary care physician Dermatologist Neurologist Other, specify:______NO, I have not seen a medical professional about this problem

15. Is the diagnosis of hyperhidrosis or the treatment of sweat disorders EXCLUDED by your insurance policy? Yes No Unknown

Past Treatment of Excessive Sweating

Please note the example below and then complete the table below by placing a checkmark in the left column for each past treatment used and fill in the remainder:

Past Treatments Length of Date Areas Results Side Effects Time Used Last treated Used Drysol 10 months March Hands, Fair Irritation, redness 2010 underarms

Past Treatments Length of Date Areas Results Side Effects/ Problems Time Used Last Treated (none, poor, (none, dryness, splits (weeks, Used fair, good, in skin, irritation, months, years) excellent) redness) Over-the-counter Anti-perspirant Drysol/aluminum chloride Drionic

Iontophoresis

Oral Anticholinergic (ex. Robinul) Other Oral Drugs (clonidine, inderal, anti-anxiety pills) Botox

Surgery

Liposuction/ Curette

Hypnosis

Acupuncture

Diet/ Fluid Changes

Other, specify: ______

Page 2 of 4 version 10/9/12 16. Please indicate how this sweating problem has affected your daily living, at work, school, relationships:

carry extra clothes avoid holding hands or intimacy avoid shaking hands think about sweating often avoid meeting new people smudge papers change clothes/shoes during day have difficulty using tools, instruments affects personal relationships impairs professional appearance or status affects the way you buy or wear clothes keep arms down to hide stains (eg. Wear layers, only dark colors) damage electronic equipment affects work Other, specify:______

17. Please list specific examples of how this sweating problem impacts your work, school and relationships: ______

18. Using the table below please mark your areas of sweating and rate them using the following Hyperhidrosis Disease Severity Scale (HDSS): 1 – My sweating is NEVER noticeable and NEVER interferes with my daily activities 2 – My sweating is tolerable, but SOMETIMES interferes with my daily activities 3 – My sweating is BARELY tolerable and FREQUENTLY interferes with my daily activities 4 – My sweating is INTOLERABLE and ALWAYS interferes with my daily activities Check Areas of Rate Current HDSS Rate your satisfaction with Excessive Sweating: per scale above current treatment : (1-4) (scale of 1-5, 1=very satisfied) Underarms Palms Soles Face Scalp Chest Back Groin Other:

19. Have you been diagnosed with any of the following: Diabetes Mellitus Cancer Thyroid Disease Tuberculosis None of these 20. Over the past months have you experienced? weight loss decreased appetite tachycardia flushing weight gain increased appetite hot flashes Other, specify:______shortness of breath menopause symptoms cough ______fever night sweats palpitations No significant symptoms

21. Check if you have any of the following: metal replacement joint/bone rod/plate/screw Pacemaker/defibrillator 22. Alcohol use: NO YES – amount (drinks/ week) ______how long? ______years 22. Are you currently pregnant or planning to become pregnant soon? NO YES (Please discuss pregnancy issues with provider before starting any medications)

23. Please note your current: Weight ______lbs Height _____ft _____in

24. Please list your occupation: ______

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25. Which best describes you: Single Married Divorced Widowed

26. Do you participate in activities that require sweating? Working out Team Sports Running Outdoor Labor None Other ______

Other Medications Certain prescription and non-prescription medications can cause excess sweating as a side effect. Below is a partial list of medicines associated with sweating. Please check any you are currently or have recently taken.

Pain Medications Antibiotics/Antivirals Heart/Blood Pressure ___Celebrex ___Acyclovir/Zovirax ___Norvasc/Amlodipine ___Hydrocodone/Vicodin ___Rocephin/Ceftriaxone ___Lotensin/Benazepril ___Toradol/ketoralac ___Cipro/Ciprofloxasin ___Bumex/Bumetamide ___Morphine ___Sustiva/Efavirenz ___Coreg/Carvedilol ___Relafen/Nabumetone ___Foscavir/Foscarnet ___Digoxin/Lanoxin ___Naproxen/Aleve ___Tequin/Gatifloxacin ___PersantineDipyridamole ___Oxycodone/Roxicodone ___Avelox/moxifloxacin ___Cardura/Doxazosin ___Ultram/Tramadol ___Ketek/Telithromycin ___Vasotec/Enalopril ___Duragesic/Fentanyl ___Ribavirin/Copegus ___Hydralazine ___Marinol ___Retrovir/AZT ___Prinivil/Zestril/Lisinopril ___Cozaar/Losartan Oncology/Cancer Skin Medications ___Lopressor/metoprolol ___Aridimex/Anastozole ___Topical steroids ___Nifedipine/Procardia ___Lupron/Leuprolide ___Accutane/Isotretinoin ___Rythmol/Propafenone ___Tamoxifen/Nolvadex ___Lidocaine/Carbocaine ___Altace/Ramipril ___Selsun/Selenium Sulfide ___Calan/Verapamil

Hormonal/Endocrine Head & Neck Medications Psychiatric/Neuro Medications ___Calcitonin/Fortical ___Aerobid/Nasarel ___Elavil/Amitriptyline ___Glucotrol/Glipizide ___Claritin/Loratadine ___Buspar/Buspirone ___Insulin/Humulin ___Sudafed/psuedoephedrine ___Tegretol/carbamazepine ___Synthroid/Thyroid ___Aristocort/Azmacort ___Celexa/Citalopram ___Depo-Provera ___Afrin/Neo-synephrine ___Clozaril/Clozapine ___Prednisolone/Orapred ___Zinc tablets/Cold-Eeze ___Norpramin/Desipramine ___Evista/Raloxifene ___Adderall/Amphetamine ___Gentropin/Somatropin Blood/Immune System ___Migranal/ergotamine ___Testosterone/Androgel ___Neoral/Cyclosporine ___Aricept/Donepezil ___Antibodies/Tositumomab ___Ferrous Gluconate/Iron ___Cymbalta/Duloxetine ___Vasopressin/Pitressin ___Remicade/Infliximab ___Lexapro/Escitalopram ___Cellcept/Mycopheolate ___Lunesta/Eszopiclone Gastrointestinal ___Prograf/Tacrolimus ___Prozac/Fluoxetine ___Lomotil/Diphenoxylate ___Haldol/Haloperidol ___Anzemet/Dolasetron Eye Medications ___Sinemet/Levodopa ___Asacol/Mesalamine ___Phospholine Iodide ___Provigil/Modafinil ___Prilosec/omeprazole ___Vasocon/Naphazoline ___Aciphex/Rabeprazole ___Alcaine/Proparacaine Lung Medications ___Advair/Fluticasone Gental/Urinary ___Combivent/Ipratropium ___Cialis/Tadalafil ___Xopenex/Levalbuterol ___Levitra/Vardenafil ___Alupent/Metaproterenol

___None of the above Thank you for assisting us with your care.

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