Childhood Eczema/Atopic Dermatitis Screening Questionnaire

YesNo
Has your child had this itchy rash at any time in the last 12 months?
YesNo
Has this itchy rash at any time affected any of the following areas: the folds of the elbows, behind the knees, the front of the ankles, under the buttocks, or around the neck, ears or eyes?
YesNo
At what age did this itchy rash first occur?
Below 5 years of ageAbove 5 years of age
Has this itchy rash cleared completely even if briefly, at any time during the last 12 months?
YesNo
In the last 12 months, how often, on average, has your child been kept awake at night by this itchy rash?
Never1 night per week1 or more nights per week
Has your child ever been diagnosed to have eczema?
YesNo