Eczema Evaluation Test

Since when have you been suffering from the skin problem?

what are the symptoms you are experiencing?

Multiple selection

Mark the areas affected by the skin lesion/White Patches?

Multiple selection

Grade of Itch

Are you getting new lesions / white patches?

Does anyone in the family suffer from similar lesion/White Patches?

Is your skin problem affecting your social life?

Are you undergoing any treatment?

What does the medicine comprise of?
Tick whereever relevant.

Multiple selection

On the scale of 1-5 rate your stress level