Eyelid Dermatitis Symptom Intake
Please provide detailed information about your eyelid dermatitis symptoms to help us understand your condition.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Contact Email Address
*
example@example.com
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Which eye or eyelid is affected?
*
Right upper eyelid
Right lower eyelid
Left upper eyelid
Left lower eyelid
Both eyes/eyelids
Describe your symptoms (e.g., redness, itching, swelling, scaling):
*
When did your symptoms begin?
*
-
Month
-
Day
Year
Date
How long have the symptoms lasted?
*
Please Select
Less than 1 week
1–2 weeks
2–4 weeks
More than 1 month
How severe are your symptoms?
*
Mild
Moderate
Severe
Possible triggers or exposures (select all that apply):
Cosmetics or skincare products
Contact lenses or solutions
Eye drops or medications
Allergens (e.g., pollen, dust, pet dander)
Recent illness or infection
Other
List any treatments or medications currently used on your eyelids or eyes:
Relevant skin, allergy, or eye history (e.g., eczema, allergies, previous eye conditions):
Submit
Should be Empty: