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

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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?
Other Duration
DateAron Regimen start date
3. Over the last week, how many days has the skin been itchy due to eczema?
4. Over the last week, how many nights has sleep been disturbed due to eczema?
5. Over the last week, how many days has the skin been bleeding due to eczema?
6. Over the last week, how many days has the skin been weeping or oozing clear fluid due to eczema?
7. Over the last week, how many days has the skin been cracked due to eczema?
8. Over the last week, how many days has the skin been flaking off due to eczema?
9. Over the last week, how many days has the skin felt dry or rough due to eczema?


Please estimate the percentage of eczema coverage of each body part.


Front of head and face
0 %
0
100 %


Front of neck
0 %
0
100 %


Back of neck
0 %
0
100 %


Back of head/scalp
0 %
0
100 %


Front of torso / groin
0 %
0
100 %


Back of torso
0 %
0
100 %


Front left arm
0 %
0
100 %


Back left arm
0 %
0
100 %


Front right arm
0 %
0
100 %


Back right arm
0 %
0
100 %


Buttocks
0 %
0
100 %


Front of left leg
0 %
0
100 %


Back of left leg
0 %
0
100 %


Front of right leg
0 %
0
100 %


Back of right leg
0 %
0
100 %

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 Scalp
0
0
3
Torso, Groin and Back
0
0
3
Shoulders, Arms and Hands
0
0
3
Legs (from hips to feet)
0
0
3

Edema or Papulation are the raised areas/bumps on skin that are sometimes pigmented



Head, Neck and Scalp
0
0
3
Torso, Groin and Back
0
0
3
Shoulders, Arms and Hands
0
0
3
Legs (from hips to feet)
0
0
3

Excoriation describes breaks in the skin surface from scratches as well as scabs from itching



Head, Neck and Scalp
0
0
3
Torso, Groin and Back
0
0
3
Shoulders, Arms and Hands
0
0
3
Legs (from hips to feet)
0
0
3

Lichenification describes the thickened leathery skin / furrowing of the skin / itchy raised nodules with a central scab or crust.




Head, Neck and Scalp
0
0
3
Torso, Groin and Back
0
0
3
Shoulders, Arms and Hands
0
0
3
Legs (from hips to feet)
0
0
3

Please provide an e-mail address below so that reminders can be sent to fill in this form at different stages of treatment.

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