Pediatric Eczema Evaluation Form
Please complete this form to help us understand your child’s eczema symptoms and history. All information will be used for evaluation purposes only.
Child’s Full Name
*
First Name
Last Name
Child’s Age
*
Parent or Guardian Name
*
First Name
Last Name
Briefly describe the primary skin concern
*
Which symptoms has your child experienced? (Select all that apply)
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Itching
Redness
Dry or scaly skin
Oozing or crusting
Thickened skin
Swelling
Other
Where on the body does the rash appear?
*
When did the symptoms start and how often do they occur?
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Are there any known triggers or aggravating factors?
*
List any current treatments or skin care products being used
*
Does your child have any allergy history or other relevant skin history?
*
Submit Evaluation
Should be Empty: