Burning Sensation Symptom Intake Form
Please provide details about your burning sensation symptoms to help us better understand your experience.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email
example@example.com
When did the burning sensation start?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Where on your body do you feel the burning sensation?
*
How severe is the burning sensation?
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
How long does the burning sensation last each time?
Are there any other symptoms present?
Redness
Swelling
Pain
Numbness
Itching
Other
Have you experienced this burning sensation before?
Yes
No
Please describe any factors that seem to trigger or worsen the burning sensation.
Submit
Should be Empty: