Skin 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 Name *FirstLastEmail *Phone *Since how may years you had skin problems? 1-5 years10-15 years 6-10 years more than 15 yearsHave you tried alternative treatment before for this condition? Yes No How long did you take treatment?How serious you think your skin condition is?MildModerate Severe What part of your skin is most affected? Head or neck arms legshandsFeetbuttocksgenitalsthighsscalpDo you feel worried about the condition of your skin? YesNoDoes anybody in the family have similar skin disorders? YesNoDoes anybody in the family have similar skin disorders? YesNoAre you a Vegetarian Non vegetarianIs there any fluid coming out of your skin? Yes NoOccasionally Do your skin get worst by season?Winter Summer Neither Does your skin get worst by open air? YesNoNeither Does your skin gets worst by shower? YesNoNeither Does your skin get better by shower? Better worst Neither Are you suffering from any allergies?Yes NoNever SometimesDo you sleep well? Yes NoDo you have constipation? Yes NoAre you suffering from diabetes? Yes NoAre you suffering from Hypertension? Yes NoWhat fabric your wear most often? Cotton Polyester Synthetic Do you take any alcoholic drinks?Daily Occasional Never Are you using cortisone or other local creams on it? Yes NoNever SometimesWhat is your body type? Cold or Chilly Normal Hot or warmNameSubmit