1.1
**1.** ___**Duration:**___ During the last 2 weeks, how many hours a day have you been itching?
1.2
**2.** ___**Degree:**___ Please rate the intensity of your itching over the past 2 weeks
1.3
**3.** ___**Direction:**___ Over the past 2 weeks has your itching gotten better or worse compared to the previous month?
**4.** ___**Disability:**___ Rate the impact of your itching on the following activities over the last 2 weeks
1.5
**Sleep**
1.6
**Leisure/Social**
1.7
**Housework/Errands**
1.8
**Work/School**
1.9
**5.** ___**Distribution**___ Mark whether itching has been present in the following parts of your body over the last 2 weeks. If a body part is not listed, choose the one that is closest anatomically.
© 2009 Fig. 2 (5-D Itch Scale). S. Elman et al. ‘The 5‐D itch scale: a new measure of pruritus.’ British Journal of Dermatology (162) 3 (2010): 587-593
5-D-Itch-Scale - United States/English
Less than 6hrs - All day
Not present - Unbearable
Completely resolved - Getting worse
Never affects sleep - Delays falling asleep
N/A - Always effects this activity
Body Parts