ATOPIC DERMATITIS (ECZEMA) Dermatology Life Quality Index (DLQI) and Atopic Dermatitis (Eczema) Questionnare *This form is only to be completed exclusively by Skin Health Institute patients before their telehealth appointment. Please enable JavaScript in your browser to complete this form.Patient Name *FirstLastDateThe aim of this questionnare is to measure how much your skin problem has affected your life OVER THE LAST WEEK. Please tick one box for each question. 1. Over the last week, how itchy, sore, painful or stinging has your skin been?Very muchA lotA littleNot at all2. Over the last week, how embarrassed or self-conscious have you been because of your skin?Very muchA lotA littleNot at all3. Over the last week, how much has your skin interfered with you going shopping or looking after your home or garden?Very muchA lotA littleNot at allNot relevant4. Over the last week, how much has your skin influenced the clothes you wear?Very muchA lotA littleNot at allNot relevant5. Over the last week, how much has your skin affected any social or leisure activities?Very muchA lotA littleNot at allNot relevant6. Over the last week, how much has your skin made it difficult for you to do any sport?Very muchA lotA littleNot at allNot relevant7a. Over the last week, has your skin prevented you from working or studying?YesNoNot relevant7b. If you selected 'No' to the above question, over the last week, how much has your skin been a problem at work or studying?Very muchA lotA littleNot at all8. Over the last week, how much has your skin created problems with your partner or any of your close friends or relatives?Very muchA lotA littleNot at allNot relevant9. Over the last week, how much has your skin caused any sexual difficulties?Very muchA lotA littleNot at allNot relevant10. Over the last week, how much of a problem has the treatment for your skin been, for example, by making your home messy or taking up time?Very muchA lotA littleNot at allNot relevantAtopic Dermatitis Questionnaire 1. ITCH - On a scale of 1-10 how severe is your itch today?0 (no itch)12345678910 (severe itch)2. SLEEP - On a scale of 1-10 how much is your skin affecting your sleep?0 (none)12345678910 (very poor sleep)3. Have you suffered from cold sores in the past 6 months?YesNo4. Have you suffered from any skin infections in the past 6 months?YesNo5a. EYES- Have you had any eye symptoms in the past 6 months?YesNoIf Yes, please rank how bothersome the following eye symptoms are below. If No, please skip to Question 6. 5b. Pain in one or both eyes (0-not at all bothersome, 9-extremely bothersome)0 (not at all bothersome)123456789 (extremely bothersome)5c. Redness in one or both eyes (0-not at all bothersome, 9-extremely bothersome)0 (not at all bothersome)123456789 (extremely bothersome)5d. Itchiness in one or both eyes (0-not at all bothersome, 3-extremely bothersome)0 (not at all bothersome)123 (extremely bothersome)5e. Discharge from one or both eyes (0-not at all bothersome, 3-extremely bothersome)0 (not at all bothersome)123 (extremely bothersome)5f. Change in vision in one or both eyes (0-not at all bothersome, 3-extremely bothersome)0 (not at all bothersome)123 (extremely bothersome)5g. Sensitivity to light in one or both eyes (0-not at all bothersome, 3-extremely bothersome)0 (not at all bothersome)123 (extremely bothersome)6. List all prescriptions or ointments used in the past 6 months below7. List all products used below (washes, moisturers etc.)8. Please select all areas affected by atopic dermatitis (eczema) in the past 6 monthsScalpFaceEars/NeckUpper LimbsLower LimbsChestAbdomenBackHandsFeetGenitalsIf on Dupixent or Rinvoq please answer the below questions How many repeats do you have left?Date of last Dupixent injectionSubmit