Scars

Name:	SSN:
Date of Exam:	C-number:
Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

NOTE: If examining multiple scars, report the data for each scar separately.

1. Type of injury or infection causing the scar or other disfigurement, and its date. For burns, provide the depth of the burn (deep partial thickness-2º, full-thickness-3º, or subdermal-4º) and percent total body surface area involved.
2. Current symptoms, including pain, skin breakdown (frequency), and other problems.
3. Describe any limitations on routine daily activities or employment due to the scar or disfigurement.

C. Physical Examination (Objective Findings):

Carefully measure all scars. Additionally measure areas of skin with certain abnormal characteristics, as specifically requested below. Report all measurements in inches or centimeters (or, when reporting areas, in square inches or square centimeters).

For every scar to be examined, address each of the following 8 items.

1. Describe precise location of each scar, using anatomic landmarks. Draw diagram if necessary. In the case of the trunk, state whether the scar is on the anterior portion, the posterior portion, or both portions. The midaxillary line on each side divides the trunk into anterior and posterior portions.
2. Give MEASUREMENT of length and width of each scar and calculate the area, for all but linear scars. Roughly describe shape of scar, if it is nonlinear.
3. Is the scar painful on examination?
4. Is there skin breakdown?
5. Is the scar superficial, meaning there is no underlying soft tissue damage?
6. Is the scar deep, meaning there is underlying soft tissue damage?
7. Describe any limitation of motion or other limitation of function caused by the scar.
8. Is there any inflammation, edema, or keloid formation? If so, describe.

In addition, for scars of the head, face, and neck and for other disfigurement of the head, face, and neck, answer the following additional 8 questions. You need not answer these questions unless the scar or disfigurement affects the head, face, or neck.

1. Provide a MEASUREMENT of the greatest width of each scar.
2. State whether the scar is adherent to underlying tissue.
3. State whether the surface contour of the scar is elevated or depressed on palpation.
4. Is there an area of abnormal texture (irregular, atrophic, shiny, scaly, etc.) of the skin? If so, provide a MEASUREMENT of the area of abnormal texture and describe the abnormal texture.
5. Is there an area of skin that is hypo- or hyper-pigmented? If so, describe color of scar compared to normal areas of skin and provide a MEASUREMENT of the area of abnormally pigmented skin.
6. Is there an area of skin that is indurated and inflexible? If so, provide a MEASUREMENT of the area of induration
7. Is there an area of underlying soft tissue loss? If yes, provide a MEASUREMENT of the area of underlying soft tissue loss and state whether or not the tissue loss is visible or palpable.
8. For the face, indicate each feature or set of paired features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips) that shows gross distortion or asymmetry.

NOTE: With disfigurement or disfiguring scar(s) of head, face, or neck, submit COLOR PHOTOGRAPHS.

D. Diagnostic and Clinical Tests:

Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:

Date: