Questionnaire about Eczema

Questionnaire about Eczema

Please answer a few questions so that we can better understand your situation.**

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Sex: Female Male	Age:
Race:	Do you have food allergy? None Dairy Products Seafood Gluten Soy Nuts Citrus Fruit Others
How many years have you had eczema? Less than 1 year 1 to 5 years 6 to 10 years 10 to 20 years over 20 years	Which part of your body does the eczema affect? Face Scalp Arm Leg Hand Foot Body
Do you know any family member who is diagnosed of eczema? Yes No	How Serious do you think your Eczema is? Mild Moderate Severe
What is your symptoms of Eczema? Red Rashes Dry Patches Oozing and blistering	Have you tried any alternative treatment? Yes if Yes, what kind? No

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**Even though we have herbal Doctors ready to answer your questions, we can not provide medical advise on-line. Your medical doctor who knows your clinical history is the only person qualified to give you medical advise. We can only guide your use of our product and let you know how our product may be able to benefit your personal case.