Confidential Questionnaire for Skin Rash

Full Name *

Email Address *

Sex: Female Male	Age:
Skin Color: Fair Medium Dark Black No Answer	Weight: (pounds)

How long have you suffered from Hives?

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 Skin Rashdo you have? Asteatotic eczema Autoeczematization Childhood Atopic Eczema Contact Dermatitis Discoid Eczema Eczema in Later Life Ear Eczema Genital Eczema in Women Gravitational Eczema Hand Eczema Herpetiformis Infantile Seborrhoeic Eczema and Cradle Cap Lichen simplex chronicus Neorodermatitis Nickel Allergy Nummular eczema Pompholyx Eczema Stasis dermatitis Seborrheic Varicose eczema Other

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

 

What is the probable cause of your Skin Rash?

Irritation and allergic reactions	Food allergies	Pregnancy	Fungal
Laundry soap, household cleaning products	Wool or synthetic clothing	Bacterial	Viral
Cosmetics, lotions, creams, perfume	Drugs, antifungal drugs or narcotic pain medications		Yeast

 

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 Hives?

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?

Internet Friends Other
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.