Toggle navigation Load unfinished survey Resume later Exit and clear survey Language: English - English English - English Français - French Nederlands - Dutch default Caution: JavaScript execution is disabled in your browser or for this website. You may not be able to answer all questions in this survey. Please, verify your browser parameters. SGP - varicella and zona 1. Identification (This question is mandatory) GP code Only numbers may be entered in this field. (This question is mandatory) Startdate of consultation week (monday) Date format: dd.mm.yyyy Open date/time selector Format: dd.mm.yyyy 1900-01-01 2037-12-31 DD.MM.YYYY (This question is mandatory) Sex patient Choose one of the following answers male female x (This question is mandatory) Is the patient pregnant? Yes No (This question is mandatory) Age of patient Only numbers may be entered in this field. Your answer must be between 0 and 110 (This question is mandatory) Which type of IDcard your patient possess? Choose one of the following answers Please choose... Belgian IDcard other identity card or residence permit issued in Belgium or other EU member state illegal migrant / without a valid residence permit tourist no answer (This question is mandatory) What is currently the patient's disease cost coverage? Choose one of the following answers Please choose... classic compulsory medical care insurance classic compulsory insurance with increased insurance allowance urgent medical assistance, social services of PCSW, Fedasil insurance of another country, private insurance none unknown/I don't know 2. Reason of consultation (This question is mandatory) Reason of consultation Choose one of the following answers varicella zona postherpetic neuralgia 3. Varicella (This question is mandatory) Vaccinated against varicella? Choose one of the following answers yes, vaccination is confirmed (I vaccinated this patient or it is mentioned in the patient record) yes, according to the patient no no, but vaccination is planned I don't know (This question is mandatory) Does the patient have immunosuppression? Yes No (This question is mandatory) Treatment with antivirals? Yes No (This question is mandatory) Which antiviral treatment? Choose one of the following answers famciclovir valaciclovir aciclovir (This question is mandatory) Antiviral treatment: how long after the onset of symptoms were they prescribed? number of days Only numbers may be entered in this field. Your answer must be between 0 and 100 (This question is mandatory) Complications? Yes No (This question is mandatory) Which complications? Check all that apply surinfection skin (e.g. abscess, necrotising fasciitis, impetigo and gangrene) pneumopathy (example: bronchitis / bronchiolitis) nose-throat-ear symptoms conjunctivitis neurological (example: meningitis) Other: (This question is mandatory) Hospitalization due to varicella? Yes No 3. Zona (This question is mandatory) History of varicella? Yes No (This question is mandatory) Vaccinated against varicella? Choose one of the following answers yes, vaccination is confirmed (I vaccinated this patient or it is mentioned in the patient record) yes, according to the patient no no, but vaccination is planned I don't know (This question is mandatory) Does the patient have immunosuppression? Yes No (This question is mandatory) Treatment with antivirals? Yes No (This question is mandatory) Which antiviral treatment? Choose one of the following answers famciclovir valaciclovir aciclovir (This question is mandatory) Antiviral treatment: how long after the onset of symptoms were they prescribed? number of days Only numbers may be entered in this field. (This question is mandatory) Vaccinated against herpes zoster (shingles)? Choose one of the following answers yes, vaccination is confirmed (I vaccinated this patient or it is mentioned in the patient record) yes, according to the patient no no, but vaccination is planned I don't know (This question is mandatory) Vaccinated against herpes zoster (shingles): which? Check all that apply Zostavax Shingrix (This question is mandatory) Vaccinated against herpes zoster (shingles): how many years ago? Only numbers may be entered in this field. Your answer must be between 0 and 100 (This question is mandatory) Hospitalization due to zona? Yes No (This question is mandatory) Ophthalmic shingles? Yes No 3. Postherpetic neuralgia (This question is mandatory) History of varicella? Yes No (This question is mandatory) Vaccinated against varicella? Choose one of the following answers yes, vaccination is confirmed (I vaccinated this patient or it is mentioned in the patient record) yes, according to the patient no no, but vaccination is planned I don't know (This question is mandatory) Does the patient have immunosuppression? Yes No (This question is mandatory) Vaccinated against herpes zoster (shingles)? Choose one of the following answers yes, vaccination is confirmed (I vaccinated this patient or it is mentioned in the patient record) yes, according to the patient no no, but vaccination is planned I don't know (This question is mandatory) Vaccinated against herpes zoster (shingles): which? Check all that apply Zostavax Shingrix (This question is mandatory) Vaccinated against herpes zoster (shingles): how many years ago? Only numbers may be entered in this field. (This question is mandatory) Which treatments are prescribed? Check all that apply tricyclisch antidepressivum corticosteroïden plasters containing lidocaine or capsaicin anti-epileptica (gabapentine of pregabaline) Other: (This question is mandatory) Hospitalization due to postherpetic neuralgia? Yes No Submit Load unfinished survey Resume later Please confirm you want to clear your response? Exit and clear survey ×
