Food-Related Contact Dermatitis Symptom Tracker Form
Use this form to record suspected food exposures, skin symptoms, timing, and possible triggers to help identify patterns related to contact dermatitis episodes.
Respondent Name or Identifier
*
Date of Symptom Episode
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date and Time of Food Exposure
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Food or Ingredients Consumed
*
Time Between Food Exposure and Symptom Onset (in hours/minutes)
*
Location of Symptoms on Body
*
Hands
Face
Arms
Legs
Torso
Neck
Other
Type of Skin Symptoms
*
Rash
Redness
Swelling
Blisters
Itching
Burning
Dryness
Other
Severity of Symptoms
*
1
2
3
4
5
Duration of Symptoms (in hours/minutes)
*
Notes About Possible Triggers or Patterns
Actions Taken or Relief Measures Used
Submit
Should be Empty: