Confidential Questionnaire for Dermatitis

Full Name *

Email Address *

Sex: Female Male	Age:
Skin Color: FairMediumDarkBlackNo Answer	Weight: (pounds)

How long have you suffered from Dermatitis?

Just Started

1 to 5 years

6 to 10 years

over 10 years

All my life

 

Which part of your body is affected?

Scalp

Face

Arm

Leg

Hand

Foot

Body

 

What type of Dermatitis do you have? Asteatotic eczemaAutoeczematizationChildhood Atopic EczemaContact DermatitisDiscoid EczemaEczema in Later LifeEar EczemaGenital Eczema in WomenGravitational EczemaHand EczemaHerpetiformisInfantile Seborrhoeic Eczema and Cradle CapLichen simplex chronicusNeorodermatitisNickel AllergyNummular eczemaPompholyx EczemaStasis dermatitisSeborrheicVaricose eczemaOther

Your skin problem is:

Mild

Moderate

Severe

 

What kind of symptoms do you have?

Itching	Inflamation	Dry Skin	Sores	Redness	Scaly	Rash
Nausea	Fever	Burning	GI Problem	Bumps	Hives	Swelling
Pain	Heat	Boils	Hair Loss	Shiny Skin	Pain	Blistering
Irritation	Discharge or Bleeding		Mood Changes		Skin Discoloration
Bloating	Thick Patches		Lack of Moisture		Sleeplessness
Flu-like sypmtoms			Blisters with oozing and crusting

 

Do you have any allergy, food intolerance or sensitivity?

Yes,  what kind?
No

Do you take any prescription and/or non-prescription drugs?

Yes,  what kind?
No

Do you have any family member who has Dermatitis?

Yes  No

Have you tried any alternative treatments?

Yes,  what kind?
No

Our QuikCure health and wellness team can customize your regimen (diet, lifestyle, detox) to uncover the true source of your problem. Would you like more information about this service? Yes  No

 

How did you hear about us?

InternetFriendsOther
Please Specify: (such as Google, WebMD, etc..)

Please add any comments and questions you have below:

This form is not designed to treat, diagnose, or cure any disease, condition or illness. It is not meant to replace attention by a medical doctor. However, our health and wellness team can answer your questions, customize your regimen, and choose the right products that work best for you.