New Patient Pre-AR Experiences and Treatments Form

[This form is for patients who have registered after 8th May, 2016.]

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1 Step 1

What is the current age of the patient?

Age

Years0123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100

Age

Months0123456789101112

At what age did the patient first show symptoms of eczema?

Age

Years0123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100

Age

Months0123456789101112

What medical professionals had the patient consulted in the year PRIOR to consulting with Dr Aron?Check all that apply

None GP Dermatologist Allergist Pediatrician Alternative medicine practitioner

Other:

In the year PRIOR to consulting Dr Aron had the patient had any skin swabs performed?Yes or No

Select An OptionYesNo

If YES what was the result of the skin swab?

PRIOR to starting the Aron Regime did the patient have any confirmed allergies?(Confirmed with a positive blood test or skin prick test. Check all that apply)

No Known Allergies Food Allergies Environmental Allergies Allergy to animals

Other

PRIOR to starting the Aron Regime HOW MANY confirmed allergies did the patient have?

Select A Number01234567891011121314151617181920212223242526272829303132333435363738394041424344454647484950

In the year PRIOR to starting the Aron Regime, did the patient show symptoms of other atopic conditions?Check all that apply

No Food Allergy Rhinitis Asthma Hayfever

Other

What TOPICAL therapies were used / tried in the year PRIOR to starting the Aron Regime?Check all that apply

Steroid Antibiotic Immunosuppressant Antifungal Antiseptic Bleach baths Avene thermal skin products Avene hydrotherapy treatment Topical probiotics NONE

Other

In the year PRIOR to the Aron Regime what type and strength of steroid or immunosuppressant creams / ointments did the patient use?if possible please list names and strengths (% or mg/ml)

0 /

What ORAL medications or therapies were used / tried in the year PRIOR to starting the Aron Regime?Check all that apply

Steroids Antibiotic Antifungal Immunosuppressants Antihistamines Oral Probiotics Elimination diet NONE

Other

In the year PRIOR to starting the Aron Regime, how frequently did the patient use a course of TOPICAL ANTIBIOTIC medications?

Select An OptionOngoing daily medications A course once a month A course(s) every few months A course a couple of times a year Rarely Never

Other

In the year PRIOR to starting the Aron Regime, how frequently did the patient use a course of ORAL ANTIBIOTIC medication?

Select An OptionOngoing daily medication A course once a month A course(s) every few months A course a couple of times a year Rarely Never

Other

In the year PRIOR to starting the Aron Regime, how frequently did the patient use TOPICAL STEROID medications?

Select An OptionOngoing daily medication A course once a month A course(s) every few months A course a couple of times a year Rarely Never

Other

In the year PRIOR to starting the Aron Regime, how frequently did the patient use ORAL STEROID medications?

Select An OptionOngoing daily medication A course once a month A course(s) every few months A course a couple of times a year Rarely Never

Other

In the year PRIOR to starting the Aron Regime, how frequently did the patient use TOPICAL IMMUNOSUPPRESSANT medications?

Select An OptionOngoing daily medications A course once a month A course(s) every few months A course a couple of times a year Rarely Never

Other

In the year PRIOR to starting the Aron Regime, how frequently did the patient use ORAL IMMUNOSUPPRESSANT medications?

Select An OptionOngoing daily medications A course once a month A course(s) every few months A course a couple of times a year Rarely Never

Other

Approximately how many moisturisers / emollients did the patient try in the year PRIOR to starting the Aron Regime?

Select A Number01234567891011121314151617181920212223242526272829303132333435363738394041424344454647484950

In the year PRIOR to starting the Aron Regime, approximately how many times a day was the patient applying moisturiser or emollient?

Select A Number01234567891011121314151617181920212223242526272829303132333435363738394041424344454647484950

In the year PRIOR to starting the Aron Regime did the patient need to wear any special clothing?(e.g. eczema suits / clothing, medical silk, scratch mitts, swaddles etc....)

Select An OptionYes, always Yes, most of the time Yes, occasionally or just at night No

In the year PRIOR to starting the Aron Regime did the patient use any wet wrapping or bandages?

Select An OptionRegularly Occasionally Never

In the year PRIOR to starting the Aron Regime how many days did the patient miss of nursery, school or work because of the eczema?(missed due to 'sick days' or doctors / hospital appointments)

Select a NumberN/A0123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180181182183184185186187188189190191192193194195196197198199200201202203204205206207208209210211212213214215216217218219220221222223224225226227228229230231232233234235236237238239240241242243244245246247248249250251252253254255256257258259260261262263264265266267268269270271272273274275276277278279280281282283284285286287288289290291292293294295296297298299300301302303304305306307308309310311312313314315316317318319320321322323324325326327328329330331332333334335336337338339340341342343344345346347348349350351352353354355356357358359360361362363364365

In the year PRIOR to starting the Aron Regime how many times was the patient admitted to hospital as an urgent or emergency case because of their eczema?

Select a Number123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180181182183184185186187188189190191192193194195196197198199200201202203204205206207208209210211212213214215216217218219220221222223224225226227228229230231232233234235236237238239240241242243244245246247248249250251252253254255256257258259260261262263264265266267268269270271272273274275276277278279280281282283284285286287288289290291292293294295296297298299300301302303304305306307308309310311312313314315316317318319320321322323324325326327328329330331332333334335336337338339340341342343344345346347348349350351352353354355356357358359360361362363364365

In the patients / carers own words please explain how the eczema has affected the patient and patients familys life?

0 /

If you are interested in being contacted to be involved in further questionnaires and studies please supply an email address in the box below.

Thank you for your time, you are helping to make a difference to other families suffering with eczema.Email

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