Body Outline Documentation Survey
Document and assess body outlines, marks, and observations for clinical or assessment purposes.
Participant Full Name
*
First Name
Last Name
Date of Documentation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email Address
*
example@example.com
Select Body Area(s) Observed
*
Head/Neck
Torso/Back
Left Arm
Right Arm
Left Leg
Right Leg
Other
Observed Features Table
*
Rows
Present
Absent
Severity (1-5)
Bruising
1
2
1
2
3
4
5
Redness
3
4
1
2
3
4
5
Swelling
5
6
1
2
3
4
5
Scarring
7
8
1
2
3
4
5
Other (specify in comments)
9
10
1
2
3
4
5
Describe Any Marks, Injuries, or Notable Features
*
Pain or Discomfort Level (0 = None, 10 = Most Severe)
*
None
0
1
2
3
4
5
6
7
8
9
Most Severe
10
0 is None, 10 is Most Severe
Upload Body Outline Image or Diagram (if available)
Upload a File
Drag and drop files here
Choose a file
Cancel
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Has the participant experienced similar features in the past?
*
Yes
No
Not Sure
Additional Comments or Notes
Signature of Participant or Observer
*
Submit Documentation
Submit Documentation
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