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ECZEMA ASSOCIATION OF AUSTRALASIA INC.
PO Box 1784 DC CLEVELAND QLD 4163
email: help@eczema.com.au
Survey    (*) indicates compulsory field
* First Name: 
* Last Name: 
Date:  27-Aug-2008
* Sufferers Name: 
* Age: 
* Street Address/PO Box: 
* Suburb: 
* State: 
* Postcode:
Date of Birth:  - -
Is the sufferer a twin, triplet, etc?:
Sex: 
Eye Colour: 
Hair Colour: 
Skin Colour: 
   
Question 1
1a. Age when eczema was diagnosed/recognised: 
1b. Age when eczema returned:
   
Question 2
2. Does the sufferer also have:   
Asthma
Hay fever
   
Question 3
3.(a) (i) Is there a history of: Eczema
If so please tick the boxes which apply:
Maternal  Paternal
Mother Father
Aunty Aunty
Uncle Uncle
Niece Nephew
Nephew  Niece
Cousin Cousin
Grandmother Grandmother
Great Grandmother Great Grandmother
Grandfather Grandfather
Great Grandfather Great Grandfather
(ii) If the sufferer is a child does he/she have:
If other please list:
3.(b) (i) Is there a history of: Asthma 
If so please tick the boxes which apply:
Maternal  Paternal
Mother Father
Aunty Aunty
Uncle Uncle
Niece Nephew
Nephew  Niece
Cousin Cousin
Grandmother Grandmother
Great Grandmother Great Grandmother
Grandfather Grandfather
Great Grandfather Great Grandfather
(ii) If the sufferer is a child does he/she have:
If other please list:
3.(c) (i) Is there a history of: Hay Fever
If so please tick the boxes which apply:
Maternal  Paternal
Mother Father
Aunty Aunty
Uncle Uncle
Niece Nephew
Nephew  Niece
Cousin Cousin
Grandmother Grandmother
Great Grandmother Great Grandmother
Grandfather Grandfather
Great Grandfather Great Grandfather
(ii) If the sufferer is a child does he/she have:
If other please list:
   
Question 4
4. (a) Is the eczema condition still current 
(b) How would you describe the severity of the condition: (please tick one box only)
Mild
Mild to Moderate
Moderate
Moderate to Severe
Severe
Chronic
Controllable
Constant
Constantly getting infected
Depending on the weather
Flares up regularly
   
Question 5
5. What sort of impact has eczema had on you or the rest of the family?  
 
No Affect (easily controllable)
Moderately (affects sleep occasionally)
Severely (disrupts sleep regularly/or hospital visits)
   
Question 6
6. List the professional people you have seen and if they were helpful or not
Medical & Natural
Professionals		 Helpful Improved Temporarily Moderately Helpful Extremely Helpful Not much Help Of no help at all
GP
Dermatologist
Dietitian
Paediatrician
Allergy Specialist
Skin Specialist
Child Health Nurse
Clinic Nurse
Chemist
Immunologist
Naturopath
Iridologist
Homeopath
Chinese Herbalist
Acupuncturist
Eczema Association
Psychoanalysist
Psychologist
Kinesiologist
Aromatherapist
Reflexologist
Herbalist
Osteopath
Health Food Shop
Photonic
Hypnotherapist
Chiropractor
   
Question 7

7. Treatments recommended: Steroid/Cortisone 
  Temporary Moderately Controlled Slight Improvement Improvement Great Improvement Excellent Results Aggravated Will Not Use
Aristocort
Advantan
Betnovate
Canestan
Celestone
Dermaid
Diprosone
Daktarin
Egocort
Elocon
Elevphrat
Hydraderm
Hydrocortisone
Imuran
Kenacomb Ointment
Novasone
Panafcort
Prednisone
Sigmacort
Logaderm
Squibb Cream
Vioform
   
  Yes No Temporary Moderately Controlled Slight Improvement Improvement Great Improvement Excellent Results Aggravated Will Not Use
Wet Dressings
Immuno-suppressants
Neoral: (Cyclosporin) 
Imuran: (Azathioprine)
Protopic: (Tacrolimus)
Elidel: (Pimecrolimus)
Other:    
   
Yes No
Antibiotics:            
  Temporary Moderately Controlled Slight Improvement Improvement Great Improvement Excellent Results Aggravated Will Not Use
Bactrim
Flucionxacillin
Resprim
Doxipin
Amoxil
   
Yes No
Antihistamines:
  Temporary Moderately Controlled Slight Improvement Improvement Great Improvement Excellent Results Aggravated Will Not Use
Claratyne
Phenergan
Zyrtec
Redipred
Polaramine Syrup
   
Yes No
Sedatives:
  Temporary Moderately Controlled Slight Improvement Improvement Great Improvement Excellent Results Aggravated Will Not Use
Valium
   
Yes No
Creams from Pharmacy:
  Temporary Moderately Controlled Slight Improvement Improvement Great Improvement Excellent Results Aggravated Will Not Use
Egozite
Cetomacrogal Cream
   
Yes No
Medical Procedures:
  Temporary Moderately Controlled Slight Improvement Improvement Great Improvement Excellent Results Aggravated Will Not Use
UV Treatment
Acupuncture
Inoculation Needles
Injection
Sodium Thiosulphate
Injections
   
Yes No
Allergy Tests
Skin Biopsy
Blood Tests
Prick Tests
Saliva Tests
  
Question 8
8. Is there something that you feel triggers off the eczema?
(b) If Yes please describe
Food Weather Stress Grasses Soaps
Others, please list:
  
Question 9
9. (a) Could you please name the brands you use for the following:
Shampoo:
Conditioner: 
Soap/Cleanser:
Bath Oil: 
Moisturizer: 
Toothpaste:
Deodorant:
Sunscreen:
Insect Repellent: 
Washing Powder:
Nappy Wash:
9. (b) Please list the ones you have tried and found to be irritating:
   
Question 10
10. (a) Has anyone ever studied the sufferer's diet:
(b) If so, what was recommended:
   
Question 11
11. (a) Are there animals at home:
What kind:
Bird/s Guinea Pig/s
Cat/s Horse/s
Chickens Kangaroo
Cow/s Mouse
Dog/s Possum
Duck/s Rabbit/s
Fish Sheep
Others, please list:
   
Question 12
12. How did you find out about the Eczema Association?
   
Question 13
13. How much would you spend on Prescription treatments per Quarter?
Other, please list:
   
Question 14
14. How much would you spend on Over the Counter treatments per Quarter?
Other, please list:
   
FOR MOTHER’S OF SUFFERERS UNDER THE AGE OF TEN WE WOULD APPRECIATE THE FOLLOWING INFORMATION
Question 15
15. (a) Were there any problems during the pregnancy:
(b) What kind:
Breech Hyperemic
Bleeding