Scars

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

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

1. Type of injury or infection causing the wound or scar, its date.
2. Current symptoms.

C. Physical Examination (Objective Findings):

For every scar to be examined, address EACH of the following and
fully describe the current findings. Note that, in addition
to measuring the scar itself, measurements of areas with certain
abnormal characteristics must also be provided. All measurements
should be reported in inches or centimeters.

1. Describe precise location of each scar. Draw diagram if
   necessary.
   
   
2. Give MEASUREMENT of length and width (at its widest part) of
   each scar.
   
   
3. Is there pain in the scar on examination?
   
   
4. Is there adherence to underlying tissue?
   
   
5. Texture of skin. If irregular, atrophic, shiny, scaly, etc.,
   give MEASUREMENT of length and width of area so affected.
   
   
6. Is the scar unstable, meaning is there frequent loss of
   covering of skin over the scar, such as from ulceration or
   breakdown of skin?
   
   
7. Is there elevation or depression of the surface contour
   of the scar on palpation?
   
   
8. Is the scar superficial (meaning there is no underlying
   soft tissue damage)?
   
   
9. Is the scar deep (meaning there is underlying soft tissue
   loss or damage)? If yes, give MEASUREMENT of length and
   width of underlying soft tissue damage.
   
   
10. Describe any inflammation, edema, or keloid formation.
    
    
11. Describe color of scar compared to normal areas of skin
    (give MEASUREMENT of length and width of any hypopigmentation
    or hyperpigmentation).
    
    
12. For face, discuss whether there is gross distortion or
    asymmetry of any feature or set of paired features (nose,
    chin, forehead, eyes (including eyelids), ears (auricles),
    cheeks, lips).
    
    
13. Is there an area of induration and inflexibility of skin in
    the area of the scar? If so, give MEASUREMENT of length
    and width of area of induration.
    
    
14. Describe any limitation of motion or other limitation of
    function caused by a scar.
    
    
15. With disfigurement or disfiguring scar 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: