Eczema Questionnaire 

For us to have the most valuable client-coach relationship I ask that you fill out this questionnaire so I can accurately determine where you are in your eczema healing journey. This will also get you familiar with some terms in my resource ebooks. Thanks!

 

Please complete the form below

Name *
Name
Please explain where on the body it is located and how large the flareups are.
Pain Scale *
Pain Scale
Please answer these statements the best you can.
I have a hard time sleeping.
I get irritable.
I experience eczema related pain daily.
My eczema feels mildly itchy
What stage of eczema are you in? *
Stage 1: Flare-ups larger than a quarter (large coin), bright red or pink in color, very itchy, very painful. Stage 2: Flesh-colored, pink, or lighter than your skin patches. Sometimes painful and often itchy. Stage 3: A few slightly itchy patches that are flakey looking
 

Download instructions:

Once submitting this form you will receive an email. Make sure to agree to subscribe (that should be the first email you get). Once you agree you will get a welcome email! Links to download the two ebooks will be in this email!