[This form is for patients who have registered after 8th May, 2016.] [] 1 Step 1 Aron Regime Patient Feedback Form 1. What is the age of the patient? 2. How long have you/your child been using the Aron Regimen?not yet started1 week2 weeks1 month3 months6 months9 months1 yearother duration Other Duration DateAron Regimen start date 3. Over the last week, how many days has the skin been itchy due to eczema?0 days 1-2 days 3-4 days 5-6 days every day 4. Over the last week, how many nights has sleep been disturbed due to eczema?no days 1-2 days 3-4 days 5-6 days every day 5. Over the last week, how many days has the skin been bleeding due to eczema?no days 1-2 days 3-4 days 5-6 days every day 6. Over the last week, how many days has the skin been weeping or oozing clear fluid due to eczema?no days 1-2 days 3-4 days 5-6 days every day 7. Over the last week, how many days has the skin been cracked due to eczema?no days 1-2 days 3-4 days 5-6 days every day 8. Over the last week, how many days has the skin been flaking off due to eczema?no days 1-2 days 3-4 days 5-6 days every day 9. Over the last week, how many days has the skin felt dry or rough due to eczema?no days 1-2 days 3-4 days 5-6 days every day Please estimate the percentage of eczema coverage of each body part. Front of head and face0 %0100 % Front of neck0 %0100 % Back of neck0 %0100 % Back of head/scalp0 %0100 % Front of torso / groin0 %0100 % Back of torso0 %0100 % Front left arm0 %0100 % Back left arm0 %0100 % Front right arm0 %0100 % Back right arm0 %0100 % Buttocks0 %0100 % Front of left leg0 %0100 % Back of left leg0 %0100 % Front of right leg0 %0100 % Back of right leg0 %0100 % Using the reference photos in each section below, compare the eczematous skin in each body region to the pictures and grade from 0-3 (half points can be used) for each eczema clinical sign. Erythema is the redness & inflammation of skin (this can be difficult to see on darker skins). Head, Neck and Scalp003 Torso, Groin and Back003 Shoulders, Arms and Hands003 Legs (from hips to feet)003 Edema or Papulation are the raised areas/bumps on skin that are sometimes pigmented Head, Neck and Scalp003 Torso, Groin and Back003 Shoulders, Arms and Hands003 Legs (from hips to feet)003 Excoriation describes breaks in the skin surface from scratches as well as scabs from itching Head, Neck and Scalp003 Torso, Groin and Back003 Shoulders, Arms and Hands003 Legs (from hips to feet)003 Lichenification describes the thickened leathery skin / furrowing of the skin / itchy raised nodules with a central scab or crust. Head, Neck and Scalp003 Torso, Groin and Back003 Shoulders, Arms and Hands003 Legs (from hips to feet)003 Please provide an e-mail address below so that reminders can be sent to fill in this form at different stages of treatment. EmailA valid email is required E-mailPlease retype above email Submit Form Previous Next
