Step
1
of
11
9%
Doctor Name
Patient ID #
*
Criteria used to diagnose atopic dermatitis
*
AAD Criteria
Hanifin and Rajka Criteria
Treatment Plan Details
*
Please provide a brief description of the treatment plan you have created for your patient.
Quantitative Data
Overall POEM score
*
POEM score for itch (Question 1 of POEM)
*
POEM score for sleep loss (Question 2 of POEM)
*
HADS-A score
*
HADS-D score
*
Patient ID #
*
Criteria used to diagnose atopic dermatitis
*
AAD Criteria
Hanifin and Rajka Criteria
Treatment Plan Details
*
Please provide a brief description of the treatment plan you have created for your patient.
Quantitative Data
Overall POEM score
*
POEM score for itch (Question 1 of POEM)
*
POEM score for sleep loss (Question 2 of POEM)
*
HADS-A score
*
HADS-D score
*
Patient ID #
*
Criteria used to diagnose atopic dermatitis
*
AAD Criteria
Hanifin and Rajka Criteria
Treatment Plan Details
*
Please provide a brief description of the treatment plan you have created for your patient.
Quantitative Data
Overall POEM score
*
POEM score for itch (Question 1 of POEM)
*
POEM score for sleep loss (Question 2 of POEM)
*
HADS-A score
*
HADS-D score
*
Patient ID #
*
Criteria used to diagnose atopic dermatitis
*
AAD Criteria
Hanifin and Rajka Criteria
Treatment Plan Details
*
Please provide a brief description of the treatment plan you have created for your patient.
Quantitative Data
Overall POEM score
*
POEM score for itch (Question 1 of POEM)
*
POEM score for sleep loss (Question 2 of POEM)
*
HADS-A score
*
HADS-D score
*
Patient ID #
*
Criteria used to diagnose atopic dermatitis
*
AAD Criteria
Hanifin and Rajka Criteria
Treatment Plan Details
*
Please provide a brief description of the treatment plan you have created for your patient.
Quantitative Data
Overall POEM score
*
POEM score for itch (Question 1 of POEM)
*
POEM score for sleep loss (Question 2 of POEM)
*
HADS-A score
*
HADS-D score
*
Patient ID #
*
Criteria used to diagnose atopic dermatitis
*
AAD Criteria
Hanifin and Rajka Criteria
Treatment Plan Details
*
Please provide a brief description of the treatment plan you have created for your patient.
Quantitative Data
Overall POEM score
*
POEM score for itch (Question 1 of POEM)
*
POEM score for sleep loss (Question 2 of POEM)
*
HADS-A score
*
HADS-D score
*
Patient ID #
*
Criteria used to diagnose atopic dermatitis
*
AAD Criteria
Hanifin and Rajka Criteria
Treatment Plan Details
*
Please provide a brief description of the treatment plan you have created for your patient.
Quantitative Data
Overall POEM score
*
POEM score for itch (Question 1 of POEM)
*
POEM score for sleep loss (Question 2 of POEM)
*
HADS-A score
*
HADS-D score
*
Patient ID #
*
Criteria used to diagnose atopic dermatitis
*
AAD Criteria
Hanifin and Rajka Criteria
Treatment Plan Details
*
Please provide a brief description of the treatment plan you have created for your patient.
Quantitative Data
Overall POEM score
*
POEM score for itch (Question 1 of POEM)
*
POEM score for sleep loss (Question 2 of POEM)
*
HADS-A score
*
HADS-D score
*
Patient ID #
*
Criteria used to diagnose atopic dermatitis
*
AAD Criteria
Hanifin and Rajka Criteria
Treatment Plan Details
*
Please provide a brief description of the treatment plan you have created for your patient.
Quantitative Data
Overall POEM score
*
POEM score for itch (Question 1 of POEM)
*
POEM score for sleep loss (Question 2 of POEM)
*
HADS-A score
*
HADS-D score
*
Patient ID #
*
Criteria used to diagnose atopic dermatitis
*
AAD Criteria
Hanifin and Rajka Criteria
Treatment Plan Details
*
Please provide a brief description of the treatment plan you have created for your patient.
Quantitative Data
Overall POEM score
*
POEM score for itch (Question 1 of POEM)
*
POEM score for sleep loss (Question 2 of POEM)
*
HADS-A score
*
HADS-D score
*
How often did you use a diagnostic tool (AAD Criteria or Hanifin and Rajka Criteria) over the past 4 months?
*
Daily
Weekly
Monthly
Not at all
Did your use of the tool impact the rate of atopic dermatitis diagnosis?
*
Not at all
Somewhat increased
Significantly increased
If so, by how much?
How often did you use the POEM assessment tool over the past 4 months
*
Daily
Weekly
Monthly
Not at all
In general, did you see a change in the patients' symptom severity through POEM? Explain, and give the changes in the POEM score if possible.
*
In general, did you see a change in the patients' satisfaction with their rash and treatment? Explain.
*
In general, did you see a change in the patients' quality of life? Explain.
*
How often did you use the HADS tool over the past 4 months?
*
Daily
Weekly
Monthly
Not at all