Dr. Roy

Childhood Eczema/Atopic Dermatitis Screening Questionnaire

    Has your child ever had an itchy rash, which came and went for at least 6 months?

    Has your child had this itchy rash at any time in the last 12 months?

    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?

    At what age did this itchy rash first occur?

    Has this itchy rash cleared completely even if briefly, at any time during the last 12 months?

    In the last 12 months, how often, on average, has your child been kept awake at night by this itchy rash?

    Has your child ever been diagnosed to have eczema?

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