SKIN BIOPSY IDENTIFICATION FORM
Ref’g Physician:______Code/Signature:______Clinical or Research (CIRCLE ONE)
Last Name:______First Name:______JHH History #:______
Previous Nerve Bx Date/Side:______LEFT/RIGHT Age:______Race:______Sex: M / F (CIRCLE)
Previous Skin Bx Date/Side:______LEFT/RIGHT Previous Bx Sites:______
Type of Fixative:______Size of Punch:______mm Time Entered into Fix:_____:_____AM/PM
Study ID#:______Study Name:______Bx. Performed By:______
Biopsy/Autopsy Date:______Autopsy #:______Post-Mortem Delay:______NDOB code:______
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Allergies to Anesthetics:______
Allergies to Adhesives:______
Anticoagulants/Bleeding Disorders:______
Surgeries:______
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Clinical Summary:
Initial Presentation of Symptoms: LEFT RIGHT BILATERALLY / LE UE OTHER
Where and to what level?______
Date of initial presentation?______
Current Presentation of Symptoms:
RIGHT / LEFT / BILATERALTOES
FEET
LEGS
FINGERS
HANDS
ARMS
TRUNK
OTHER
R=L R>L L>R (CIRCLE if applicable)
Are symptoms constant or variable? ______
Classification/Description of Symptoms:
(CIRCLE) Burning Tingling Numbness Pins&Needles Electric Shocks
______
______
Tight Icy Itchy ”Wormy/Buggy” Feeling Stabbing Aching Cramping
______
______
Neuropathy Cause (if known):______
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Punch Sites and Number: D.Leg: ______L / R Toe: ______L / R Back: ______L / R
D.Thigh: ______L / R Heel: ______L / R Chest: ______L / R
P.Thigh: ______L / R Arm: ______L / R Abdomen: ______L / R
Calf: ______L / R Shoulder: _____ L / R Other: ______L / R