Patient details

1.  Male/Female                            Please select Male Female

2. What year did you have NF?                   How old where you then?

3. Ethnic Group please tick:-         Please select British (white) Other (white) White/Black Caribbean White/Black African Asian Indian Any other group

4. Are you the patient or relative? Please select Patient Relative

Clinical Details – Pre admission

5. Were you/the patient a diabetic at the time of infection?         Yes No

       If yes, type one (injection) or type two (tablets)                  Please Select Injection Tablet

6.  Were you/ the patient taking steroids?                                  Yes No

       If yes which drug and for what condition?
                                                                                               

7. Were you/the patient on any other immunosuppressive
       treatment (e.g. treatment that you have been 
       informed would weaken your immune system and
       lower your resistance to infection)?
                                                                                               

8. Please list any non – steroidal drugs you had
       taken (eg; ibuprofen/volterol/diclofenic) prescription
       or non  prescription

       The day before…………………..                                   

       Or as routine……………………                                    

9. Had you/the patient been in hospital                                      Yes No
     within the last 6 weeks prior to feeling poorly?

a)If YES was this as an in patient or out patient?                       Please Select In Patient Out Patient
       b)What was the reason for this?                                        
       c)Please supply the date.                                                  

10. Had you/the patient had any surgery or radiotherapy           Yes No
       previously on the part of the body that was later 
       affected with this infection?

       If YES please explain further (when and for what reason)  

11. Was anyone else in the family or a close contact                 Yes No
       affected with a skin infection or sore throat?  

       If Yes, please give the approx date                                   
       Please explain further

12. Have you/the patient ever been diagnosed with                   Yes No
      cellulites or fasciitis before this time?

13. Had you/the patient had any septic spots or pus                  Yes No
      from anywhere in the 2 wks before you were unwell?

14. Had you/the patient broken or bruised any area                  Yes No
      of the skin in any way before becoming unwell? 
      If YES please give details, where and when?                      

15. Do you/the patient believe your immunity was                     Yes No
      low the week prior to this infection (e.g. were you
      recovering from another infection or illness?
      If YES, please give details.                                                

16. Did you/the patient have any flu-like illnesses                      Yes No
      or shivers or shakes?

17. Did you/the patient have a body rash at any time?               Yes No            
      If YES at what time did you/they notice it?                         

18. Did you/the patient suffer any pain before admission?          Yes No

19. Did you/the patient feel pain at the site,                               Yes No
       which was affected? 
       If so on a scale of 0 – 10, with 10 being unbearable,          PLease Select 1 2 3 4 5 6 7 8 9 10
       how bad was the pain at the beginning?

20. Did the pain ever go completely before                               Yes No
       you were treated?
       Did the affected part become numb?                                  Yes No

21. Did you/the patient take any painkillers?                              Yes  No                
  a)If YES which ones and at what time approx?                      

22. Did you/the patient seek medical attention                           Yes No
       when you/they began to feel ill? 
      If YES how long was it before you were seen?
       By GP?                                          Or Hospital Doctor?             

23. Did you/the patient phone NHS Direct?                              Yes No
       a) If YES what did they suggest may be wrong?                                              
       b) What did they advise?                                                  

24. Were you/the patient advised to take non- steroidal            Yes No
       drugs (anti-inflammatory drugs like ibuprofen/brufen
       diclofenac,volterol) by anyone
       If so who by?                                                                   

25. Did you/the patient take anything                                        Yes No
      for the pain/temperature?         
      Please give the details.                                                       

26. If you/the patient was sent home after seeing/speaking         Yes No
       to the GP, did you/they go back to your GP or seek  
       an other source of medical help when you/the patient
       started to feel worse?
       Why did you/the patient decide to do this at this stage?     

27. What was you/the patient feeling like?                                 Please Select Rash Pain Vomiting Diarrhoea
      (symptoms ie;,rash/pain/vomiting/diarrhoea/bruising etc).
                                                                                      Other

Questions on Admission

28. When you first arrived at (A&E) the hospital,                      Please Select up to 1 hour 1 -2 hours 2-3 hours 3-4 hours More than 4 hours
       how long did you/the patient have to wait before
       you were first examined by a doctor?

29. What were the symptoms like when you were examined     
       by the doctor?

30. After examining you/the patient,                                         
       what did the doctor say was probably wrong?

31. Had you/the patient been vomiting?                                    Yes No                       
       a) Had you/the patient had diarrhoea?                               Yes No

32. Had you/the patient been hallucinating                                Yes No
       or muddled or confused?
       Please give details.                                                           

33. What colour was the skin area affected by this time?           Please Select Red Blue Other

34. Was there blistering?                                                          Yes No

35. Was the area affected red and angry?                                 Yes No                          
     a)If so did the doctors draw a line around it?                        Yes No

36.Were photographs of the affected area taken?                     Yes No

37.What specimens were taken – if any?                                
   a) Blood, Swabs – eg;                                                          Yes No
   b) Throat swab or wound or from a blister?                          Yes No
   c)Were you/the patent sent for X – rays?                              Yes No                    
   d)MRI scan?                                                                        Yes No                    
   e) Or any other imaging?                                                       

38. What treatment did you have at this time                            
        i.e.; antibiotics?

39. If you cannot remember,                                                     Please Select Intravenous Mouth
       were they intravenous (given by drip) or by mouth?

40. Was NF diagnosed at this stage?                                        Yes No                 
   a) Were you informed?                                                          Yes No

41 When did a surgeon or plastic surgeon see you?                  

42. How long after arrival at A&E was surgery performed?      

43. Did you/the patient go to intensive care?                             Yes No
      a) If so was this for post-operative monitoring?                   Please select Post - operative monitoring Deteriorating condition
          Or as a result of deteriorating condition?
      b) If so total number of days?                                            

44. How many operations did you/the patient need to have?     
   a)Also skin grafting?                                                             

45.How long was your/the patient’s stay in hospital?                 Days

46.Did the patient die as a result of this infection                       Yes No
     and if so when?                                                                   Please enter the date

47.Please give details of anything here that you think
      may have affected the speed of diagnosis or outcome.        

48.Was anyone else in the household                                       Yes No
      swabbed or given antibiotics?

49. Did anyone explain to you what type of                              Yes No
      bacteria caused the infection?           

50. Did anyone discuss with you the after care                          Yes No
      i.e.; counselling/tissue care/creams/skin grafts when leaving
      the hospital?

51. How did you hear about The Lee Spark NF Foundation?   Please Select Word of mouth News paper Magazine Internet

Thank you for completing this form and we do apologise if these questions have upset you. But every answer will be extremely useful.

If you feel we have missed anything that you feel is relevant, please use this area to let us know:

Your details;

Title Please Select Mr Mrs Miss First Name Last Name

House Number      
Street                    
Town                    
Post Code             

Day time telephone
Mobile Number     
Email Address