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Life Eczema Assessment worksheet

1 - I can do better 2 - Jury's out 3 - Pretty darn good 4 - Splendiferous 5 - Awesometastic (by 0 people)   Your rating: 1 - I can do better 2 - Jury's out 3 - Pretty darn good 4 - Splendiferous 5 - Awesometastic

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What is Life ?

 

Life : Life Improvement For Eczema

The Life Assessment Tool 

This simple worksheet was designed by the National Eczema Association to help eczema patients and their doctors deal with the quality of life issues associated with Eczema.

This worksheet should be completed by the eczema patient (or parent) before meeting with their doctor.

Questions 

Circle the number that most closely matches your situation.

Patient name:
Date of birth:
Date:

Bring with you to your next Doctor's visit.
Provide any additional information or comments on the impact eczema has on your life:
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
  1. How often do you/your child have the rash/eczema ?
    Yearly Every-Few-months Monthly Weekly Daily
    ...1.............2......................3...........4........5
  2. How often do you/your child itch from eczema ?
    Never Rarely Sometimes Often All-the-time
    ...1......2.............3.............4........5
  3. How often does eczema interfere with sleep ?
    Never Rarely Sometimes Often All-the-time
    ...1......2.............3.............4........5
  4. How often does having eczema interfere with work, school, or recreational activities ?
    Never Rarely Sometimes Often All-the-time
    ...1......2.............3.............4........5
  5. How often does having eczema affect daily friendships, social life, or family/friend gatherings ?
    Never Rarely Sometimes Often All-the-time
    ...1......2.............3.............4........5
  6. How often does having eczema make you/your child sad, embarrassed, or upset ?
    Never Rarely Sometimes Often All-the-time
    ...1......2.............3.............4........5

    Score:add score for each question (maximum 25) Total ________

    1-8: Mild 9-16: Moderate 17-25: Severe

Front Body Surface Area 

Shade the areas where you have recently experienced eczema.

Back Body Surface Area 

Shade the areas where you have recently experienced eczema.

Link List 

Life (pdf version)
Life assessment tool .pdf version
Eczema - Wikipedia, the free encyclopedia
Eczema From Wikipedia
NEASE | Life Improvements for Eczema
Life
National Eczema Association | NEA(sm)
NEA works to improve the health and the quality of life of persons living with atopic dermatitis/eczema, including those who have the disease as well as their loved ones.

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