Patient’s Chronic Urticaria Scoring Sheet
Patient:_____________________________________________________
Please check the most appropriate box for 1) Number of Hives (left side of chart) and 2) Severity of
itching (right side of chart). Indicate the most accurate description for either the morning or the
evening. Please circle the day of the week that you started scoring. Use one sheet per week.
Date Started:
_________________
[Score]
Sunday AM
Sunday PM
Monday AM
Monday PM
Tuesday AM
Tuesday PM
Wednesday AM
Wednesday PM
Thursday AM
Thursday PM
Friday AM
Friday PM
Saturday AM
Saturday PM
Score (total value
in each column)
Maximum
Date Started:
_________________
[Score]
Sunday AM
Sunday PM
Monday AM
Monday PM
Tuesday AM
Tuesday PM
Wednesday AM
Wednesday PM
Thursday AM
Thursday PM
Friday AM
Friday PM
Saturday AM
Saturday PM
Score (total value
in each column)
Maximum
Number of hives present
Hives
Hives
Hives
0
1-20
2150
0
1
2
0
14
28
Number of hives present
Hives
Hives
Hives
0
1-20
2150
0
1
2
0
14
28
Hives
>50
Severity of Itching
Itching
Itching
None
Mild
Itching
Moderate
Itching
Severe
3
0
2
3
42
0
Hives
>50
3
42
1
28
42
Severity of Itching
Itching
Itching
None
Mild
Itching
Moderate
Itching
Severe
0
2
3
0
14
1
14
28
42
Total
numbers
for AM,PM
Total
##/2
______
(Max
84/2=42)
Total
numbers
for AM,PM
Total
##/2
______
(Max
84/2=42)