Eczema Questionnaire | Dermatology

Question 1

How is the severity of the eczema in summer as compared to winter?

Definitely improves

Probably improves

About the same

Probably worsens

Definitely worsens

Not sure/Not applicable

How is the severity of the eczema in a tropical environment as compared to a dryer climate?

Definitely improves

Probably improves

About the same

Probably worsens

Definitely worsens

Not sure/Not applicable

My child's skin feels dry to touch

Definitely true

Probably true

Not really

Not sure

I feel that a regular moisturiser is very important in controlling my child's eczema

Definitely true

Probably true

It makes little difference

Not sure

Swimming in chlorinated swimming pools affects the eczema in what way?

Definitely worsens

Probably worsens

It can improve it

Not sure/not relevant

As a baby, teething seemed to cause eczema around the mouth

Definitely true

Probably true

It did not

Not sure

Rough fabrics such as wool feel prickly on the skin and/or flare the eczema

Definitely true

Probably true

Not really

Not sure

My child's eczema seems to flare when they are overheated

Definitely true

Probably true

Not really

Not sure

My child has had positive skin prick tests or RAST blood tests to certain foods

Yes

Has had test but negative

Not sure

Hasn't been tested

I can predict that with certain foods that eczema will flare

Yes every time guaranteed with certain foods

At times occurs

There doesn't seem to be a correlation

The eczema seems to worsen in certain environments (e.g. visiting certain relative's house)

Definitely true

Probably true

Not really

Not sure

My child has also been diagnosed with hay fever (allergic rhinitis)

Yes

Maybe

My child has also been diagnosed with asthma

Yes

Maybe

My child has been given oral antibiotics for their eczema

Yes

Unsure

My child's eczema improves when taking antibiotics

Definitely true

Probably true

Not really

Not sure/hasn't had any

My child does seem to scratch even normal looking skin

Definitely true

Probably true

Not really

Not sure

At times, my child can go to bed with relatively clear skin yet can wake from scratching

Definitely true

Probably true

Not really

Not sure

My child's eczema seems to flare at change of seasons

Definitely true

Probably true

Not really

Not sure

My child's eczema tends to take the form of small coin sized plaques

Yes primarily like this

Yes in some areas

Not really

Not sure

No matter how I care for the skin, there are some patches of eczema that never seem to clear

Definitely true

Probably true

Not really

Not sure

When I apply creams to my child's skin, they tend to sting

Always

Mostly

Sometimes

Never

Which statement best describes your use of topical steroid creams on the eczema

I haven't used any topical steroids

I use them on the worst areas only

I will only use them for a set number of days then stop

I will use them on all eczema areas until they are cleared

Which statement best describes how thickly you apply the steroid creams

I haven't used any topical steroids

I apply very sparingly

I am careful with the application of the topical steroids

I use them as I would any other cream like a moisturizer or sunscreen

In general terms what is the eczema like on the upper part of the face (around eyes and forehead)?

Bad persistent area

Occasional affected area

Generally unaffected area

In general terms what is the eczema like on the lower part of the face (around mouth and neck)?

Bad persistent area

Occasional affected area

Generally unaffected area

In general terms what is the eczema like on the front of the elbows and/or the back of the knees?

Bad persistent area

Occasional affected area

Generally unaffected area

In general terms what is the eczema like on the hands?

Bad persistent area

Occasional affected area

Generally unaffected area

In general terms what is the eczema like in the trunk?

Bad persistent area

Occasional affected area

Generally unaffected area

In general terms what is the eczema like on the arms and legs?

Bad persistent area

Occasional affected area

Generally unaffected area

In general terms what is the eczema like on the scalp?

Bad persistent area

Occasional affected area

Generally unaffected area

Please rate how your child's eczema was in the first year of life

Very bad

Some good and some bad

Occasional only

Hardly any to no eczema

Not relevant/unsure

How old is your child?

Less than 1

1-3 years old

4-9 years old

10 years or older

With regards to the number of lines on the palm of your child's hand

They seem to have similar or fewer palm lines than most people

They seem to have slightly more palm lines than most people

They seem to have significantly more palm lines than most people

Dermatology

Questionnaire

Question 1

How is the severity of the eczema in summer as compared to winter?

Question 2

How is the severity of the eczema in a tropical environment as compared to a dryer climate?

Question 3

My child's skin feels dry to touch

Question 4

I feel that a regular moisturiser is very important in controlling my child's eczema

Question 5

Swimming in chlorinated swimming pools affects the eczema in what way?

Question 6

As a baby, teething seemed to cause eczema around the mouth

Question 7

Rough fabrics such as wool feel prickly on the skin and/or flare the eczema

Question 8

My child's eczema seems to flare when they are overheated

Question 9

My child has had positive skin prick tests or RAST blood tests to certain foods

Question 10

I can predict that with certain foods that eczema will flare

Question 11

The eczema seems to worsen in certain environments (e.g. visiting certain relative's house)

Question 12

My child has also been diagnosed with hay fever (allergic rhinitis)

Question 13

My child has also been diagnosed with asthma

Question 14

My child has been given oral antibiotics for their eczema

Question 15

My child's eczema improves when taking antibiotics

Question 16

My child does seem to scratch even normal looking skin

Question 17

At times, my child can go to bed with relatively clear skin yet can wake from scratching

Question 18

My child's eczema seems to flare at change of seasons

Question 19

My child's eczema tends to take the form of small coin sized plaques

Question 20

No matter how I care for the skin, there are some patches of eczema that never seem to clear

Question 21

When I apply creams to my child's skin, they tend to sting

Question 22

Which statement best describes your use of topical steroid creams on the eczema

Question 23

Which statement best describes how thickly you apply the steroid creams

Question 24

In general terms what is the eczema like on the upper part of the face (around eyes and forehead)?

Question 25

In general terms what is the eczema like on the lower part of the face (around mouth and neck)?

Question 26

In general terms what is the eczema like on the front of the elbows and/or the back of the knees?

Question 27

In general terms what is the eczema like on the hands?

Question 28

In general terms what is the eczema like in the trunk?

Question 29

In general terms what is the eczema like on the arms and legs?

Question 30

In general terms what is the eczema like on the scalp?

Question 31

Please rate how your child's eczema was in the first year of life

Question 32

How old is your child?

Question 33

With regards to the number of lines on the palm of your child's hand

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