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Приложение 1.

Протокол исследования пациента с гнёздной алопецией №

1. Ф.И.О.

2. Дата приёма

3. Возраст

1.5 Пол Муж. Жен.

1.6 Расовая принадлежность:

конт. тел.

4. Дата рождения

1. Европеоидная 1.6.3 Негроидная

1. славянин

2. скандинав

3. средиземноморский тип

1.6. 2 Монголоидная

1.7 Преимущественный цвет волос

1. Чернокожий африканец

2. Чернокожий латиноамериканец

1.6.4 Национальность

1. Черный

2. Коричневый

3. Рыжий

4. Серый

5. Блондин

6. Белый

2. Анамнез пациента и членов его/ее семьи

Анамнез пациента и членов его/ее семьи

Пациент

Мать

Отец

Сын

Дочь

Брат

Сестра

Бабушка по линии матери

Дедушка по линии матери

Бабушка по линии отца

Дедушка по линии отца

Тетя по линии матери

Дядя по линии матери

Тетя по линии отца

Дядя по линии отца

Атопический дерматит

Аллергический ринит

Астма

Заб-е щитовид. железы

Тиреоидит Хашимото

Болезнь Грейвса

Витилиго

Сахарный диабет

типа 1

типа 2

неизвестный тип

Систем. красн. волчанка

Злокачественная анемия

Ревматоидный артрит

Язвенный колит

Глютен. б-нь (целиакия)

Псориаз

Прочие а/им заб-я

Тип

Синдром Дауна

Иммунодефицит

Тип

Гнёздная алопеция

Прочие заболевания

2. Анамнез гнездной алопеции:

   1. Количество предшествующих эпизодов гнездного облысения

   2. Возраст в момент начала 1-го эпизода гнездного облысения

   3. Первый эпизод гнездного облысения (месяц/год начала)

   4. Анамнез тотальной формы или тотальной/универсальной формы ГА, возникавшей в какое-либо время:

      1. продолжительностью >2 лет

      2. продолжительностью ≤2 лет

5. Текущий эпизод гнездного облысения:

1. Возраст начала

2. Месяц/год начала

3.5.2 Продолжительность текущего эпизода (месяцы):

3.5.3.1	< 3 мес,	3.5.3.4	>2-5 лет,
3.5.3.2	3–12 мес,	3.5.3.5	>5 лет.
3.5.3.3	12–24 мес