Rosacea Symptom Questionnaire Form
Please complete this form to help assess your rosacea symptoms and identify possible triggers.
How often do you experience facial redness?
*
Rarely
Occasionally
Frequently
Almost always
Rate the severity of your facial flushing.
*
None
1
2
3
4
Severe
5
1 is None, 5 is Severe
Do you experience visible blood vessels (spider veins) on your face?
*
Yes
No
Not sure
How often do you experience bumps or pimples on your face (not acne)?
*
Never
Rarely
Sometimes
Often
Do you experience eye symptoms (such as dryness, irritation, or redness) related to your rosacea?
*
Yes
No
Not sure
How sensitive is your skin to skincare products or cosmetics?
*
Not sensitive
1
2
3
4
Very sensitive
5
1 is Not sensitive, 5 is Very sensitive
Which of the following triggers do you notice worsen your symptoms? (Select all that apply)
*
Sun exposure
Hot or cold weather
Spicy foods
Alcohol
Stress
Exercise
Other
Describe any other symptoms you experience with your rosacea.
At what age did you first notice rosacea symptoms?
If you have identified any specific triggers not listed above, please specify:
Submit
Should be Empty: