NPA's Reporting Registry Survey

National Pediculosis Association's
Reporting Registry Survey

Patient Information

Please answer the questions in every section with respect to the patient only, not the parent(s), sibling(s), spouse, significant other, or any other household member. It is important that all questions be answered. If a question does not apply to the patient then check "not-applicable".

Note that we no longer collect information with this form, but we welcome you to fill it out and hit the "PRINT THIS QUESTIONNAIRE" to keep a record.

First name:	Last name:
Address:	City:		State:	Zip:
Phone #:	Date of birth:	//
Sex:	Patient Is:

Section 1: Patient Diagnostic Information

What was the patient treated for? Other:

Who diagnosed the patient's lice and/or scabies infestation? Other:

Questions 3-5 refer to the adverse event symptoms you
believe were caused by lice and or/scabies treatment products.

How long after lice and/or scabies treatment(s) were the
symptom(s) first noticed?

Did the patient or patient's guardian consult a medical professional regarding the same symptoms
that were reported to the NPA's registry?

*Which professional or professionals were contacted? Check all that apply.
family physician	neurologist	other	not-applicable
pediatrician	dermatologist	unsure

If the patient or patient's guardian contacted a medical professional, (during the medical history taking)
were any questions asked about lice and/or scabies treatments?

Section 2: Patient Treatment Information

Was the patient's treatment with a lice and/or scabies product used for the sole purpose
of preventing an infestation?
Did the patient or patient's guardian understand that the treatment product(s) is a pesticide?
How many applications of the lice and/or scabies products did the patient receive?
Were verbal or written instructions given to the patient or patient's guardian regarding the patient's
use of the lice and/or scabies treatment product?
How old was the patient exposed to the lice and/or scabies product?
Did the patient apply the lice and/or scabies product to him or herself?
Did the patient apply the lice and/or scabies product to anyone else?

*If YES, how many other people did the patient treat with a lice and/or scabies product?

Section 3: Patient Lice Treatment Information

Section 4: Patient Scabies Treatment Information

The following section is for patients who have been treated for scabies.
If patient was treated for lice only check "not-applicable" for question 1.
If patient was treated for both lice and scabies fill out this section and section 3 as well.

Which scabies treatment product(s) was applied to the patient? Check all that apply.

Kwell or any lindane product	Elimite	other	not-applicable
combination of 2 or more scabicides	Eurax	unsure

Was the scabies treatment product applied to the patient's entire body?
How long was the lice treatment left on the patient's head or genital area?
Was the patient's diagnosis of scabies based on a diagnostic test of any kind?

Section 5: Patient Exposure To Chemicals

Was a pesticidal spray recommended?
Was a pesticidal spray, fog, or bomb used in the patient's home, car or workplace?

*If YES, how many times?

If the patient or patient's guardian used a pesticidal spray in the place of residence,
what was the name of the pesticidal spray used? Check all that apply.

A-200	Pronto	R&C	unsure
store brand	RID	other	not-applicable

Are chemicals used on the patient's garden or lawn?

*If YES, how often?
Do any of the patient's neighbors use a lawn service requiring chemical treatments?
Does a professional pest exterminator service the patient's home?
Does the patient have a cat or dog?

*If YES, do they wear flea collars or get "dipped"?
Does the patient swim in a chlorinated pool?

*If YES, how often does the patient swim in the pool?
Does the patient's family use a natural Christmas tree in the home?

*If YES, how many weeks is the tree left up?
Has the patient ever smoked cigarettes?

*If YES, how many packs a day does (did) the patient smoke?
Do any patient's household members smoke?

*If YES, how many packs a day?
Does the patient or any household member have exposure to chemicals
at their place of employment?
Is there a fireplace or wood burning stove used in the patient's home?
Does patient pump his/her own gasoline?
Do any of the patient's household members pump their own gasoline?

Section 6: Patient Background Information

Was the patient pregnant at the time of treatment?

*If YES, was the birth premature?
Was the patient nursing at the time of treatment?

Did the patient have any of the following medical problems at the time of his or her own birth? Check all that apply.

meconium (bowel movement)	jaundice	unsure
blue extremities	other	not-applicable

*If OTHER, please specify:

Was the patient born with any birth defects?

*If YES, please specify:

Section 7: Patient Symptoms

Below is a list of symptoms. IT IS IMPORTANT TO DETERMINE IF AND WHEN ANY OF THE FOLLOWING SYMPTOMS WERE EXPERIENCED BY THE PATIENT before and/or after use of a lice and/or scabies treatment product. Please answer the following questions by checking the appropriate line for each symptom. Please check one box for each symptom.

Has the patient ever received a medical diagnosis for a condition, illness or disease that may be related
to an exposure to a lice and/or scabies treatment product?

*If YES, please list all that apply:

Thank you for completing this survey. If you have any additional information or comments, or suspect
any other household member may be experiencing an adverse reaction to a lice and/or
scabies treatment product please describe below.

Information for the person who filled out this form:
check here if same as patient info at the beginning of the form
First:	Last:
Address:	City:	State:
Zip Code:	Phone #
Relationship to patient:

Original Form Submission Date: //

Have you completed and reviewed the report?

PRINT THIS QUESTIONNAIRE