COALESIA Patient Program — Initial Patient Assessment

1. Patient information

Full name Date of birth Age Country City Preferred language Phone WhatsApp Email Time zone

Caregiver / contact person Contact person phone

Skin problem and symptoms

Main complaint

Where are the skin changes located? How long have the changes been present? How did the condition begin? Distribution

Which symptoms are present?

Itch severity, 0–10 Pain level 0–10

Urgent warning signs

Fever Rapid spread Swelling of the face, lips or tongue Difficulty breathing Mucosal involvement Extensive blistering or skin detachment Very severe pain Blackening or skin necrosis

If any of these warning signs are present, this remote questionnaire does not replace urgent in-person assessment.

History and possible causes

Previous skin diagnoses Known allergies Possible triggers Family history of skin disease

Diabetes mellitus Immune or autoimmune disorder Pregnancy Recent infection New medicine before symptoms began New cosmetic or household chemical Animal contact Recent travel

Bowel function

How often do you have a bowel movement?

Do you have any bowel disturbances?

Constipation Diarrhea Alternating constipation and diarrhea Bloating Pain or discomfort Blood or mucus in stool No disturbances

Other features or details

Antiparasitic treatment history

Have you previously completed antiparasitic treatment or a preventive course?

When did you complete the course? Which medicines or products did you use? Who recommended the course? Did you notice any changes in your well-being after the course?

Additional comment

Treatment and photographs

How is the wound currently treated? How did the condition change with treatment?

Please attach photographs of the skin changes:

Overview showing the area and its body location
Close-up in good lighting
If several areas are involved, a separate photo of each

Use good natural light and no filters. Maximum 12 files, up to 10 MB each. JPG, PNG, WEBP or PDF.

Choose files

7. Consent and submission

Additional information

I consent to processing my personal and medical information for remote assessment. I understand that remote assessment is not a final diagnosis and does not replace in-person or emergency care. I separately consent to anonymous use of photographs and case history for educational or scientific materials. Refusal does not affect medical support.

After submission, the information will be stored in the center’s protected administrative system.

Initial Remote Clinical Assessment Form

Skin Condition Questionnaire