# OpenScar Clinician Intake Form

Use this form during baseline and follow-up visits to capture scar and keloid information in a schema-compatible structure.

Do not place names, full dates, medical record numbers, phone numbers, addresses, or unredacted identifiable image links in this form.

## Visit Setup

- `patient_id`:
- `lesion_id`:
- `visit_id`:
- `visit_date_offset_days`:
- `visit_type`: baseline / treatment / follow_up / complication / recurrence_check / other
- Clinician reviewer:
- Research export allowed: yes / no / unknown

## Patient Context

Maps to `patient`.

- `sex_at_birth`:
- `age_at_first_visit`:
- `fitzpatrick_skin_type`:
- `relevant_history`:
- `comorbidities`:
- `consent_status`:

## Lesion Phenotype

Maps to `lesion`.

- `scar_category`: keloid / hypertrophic_scar / atrophic_scar / contracture / postoperative_scar / burn_scar / other / uncertain
- `anatomic_site`:
- `laterality`: left / right / midline / bilateral / not_applicable / unknown
- `presumed_trigger`: surgery / trauma / acne / piercing / burn / injection / spontaneous / unknown / other
- `onset_date_precision`: exact_date / month / year / estimated / unknown
- `duration_months_at_baseline`:
- `baseline_symptoms`:

## Clinical Visit Assessment

Maps to `visit`.

- `clinician_assessment`:
- `patient_reported_pain`:
- `patient_reported_itch`:
- `patient_satisfaction`:
- `validated_scale_name`:
- `validated_scale_score`:

## Treatment Exposure

Maps to `treatment`. Repeat when multiple interventions are delivered during the same visit.

- `treatment_id`:
- `treatment_modality`: steroid_injection / 5fu_injection / botulinum_toxin / laser / rf_microneedling / surgery / radiotherapy / silicone / pressure / cryotherapy / other
- `treatment_detail`:
- `combination_flag`: true / false
- `adverse_event_reported`: true / false
- `adverse_event_detail`:

## Outcome Assessment

Maps to `outcome`. Complete only when a response or recurrence window is being assessed.

- `outcome_id`:
- `assessment_visit_id`:
- `follow_up_days_from_baseline`:
- `response_category`: improved / stable / worse / recurrence / partial_recurrence / uncertain / not_assessable
- `recurrence_status`: yes / no / suspected / not_assessed
- `recurrence_definition`:
- `functional_impact`:
- `cosmetic_impact`:
- `outcome_confidence`: high / moderate / low

## Clinician Sign-Off

- Direct identifiers removed from research fields:
- Image governance checked:
- Patient-reported fields separated from clinician impression:
- Ready for registry entry: