Eczema Psoriasis Questionnaire 940 E. El Camino Real Sunnyvale, CA 94087 harminder@homeopathicvibes.com www.homeopathicvibes.com Office Phone (408)737-7100 Office Fax (408)737-7102 Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Since how may years you had Eczema/Psoriasis? 1-5 years6-10 years10-15 yearsmore than 15 yearsHave you tried alternative treatment before for this condition? YesNoHomeopathicAllopathicAyurvedicUnaniHow long did you take treatment?How serious you think your eczema/ Psoriasis is? MildModerateSevereWhat part of your skin is most affected?Head or neckArmsLegsBackFaceDo you feel worried about the condition of your skin?YesNoDoes any body in the family have same skin disorder?YesNoDoes it affect your day to day life? YesNoAre you aVegetarianNon vegetarianWhat is color of effected skinRedDry patchesOozing and blistersIs there any fluid coming out of your skin?YesNoOccasionallyDo your skin gets worst by season?WinterSummerNeitherDo your skin gets worst by open air?YesNoNeitherDo your skin gets worst by shower?YesNoNeither Does your skin gets better by shower?BetterWorstNeitherAre you suffering from any allergiesYesNoNeverSometimes If yes….Please mention the food or items allergic to….Do you sleep well? YesNoDo you have constipation?YesNoAre you suffering from diabetes?YesNo If yes, are you taking any medication? Please mentionAre you suffering from Hypertension?YesNo If yes , are you taking any medication? Please mention What fabric your wear most often?CottonPolyesterSyntheticDo you take any alcoholic drinks? DailyOccasionalNeverAre you using cortisone or other local creams on it?YesNoNeverSometimes What is your body type? Cold or ChillyNormalHot or warmMessageSubmit