redness		dryness		lesions in skin folds		tightness
burning sensations		intense itching		flaking		none of the above
Specify any others:
Since when?
Check appropriate box:
birth		1 to 6 months		6 to 12 months
1 to 3 years		3 to 6 years		6+ years
How long do these signs last?
a few minutes		a few hours		1 day
several days		permanently

Environmental factors	yes	no
cold
heat
humidity
sun
sudden changes in temperature
smoking environment
pollution
dust mites
mold
Physical factors	yes	no
perspiration
contact with synthetic fabrics (nylon, polyester)
dietary allergens (food intolerance)
Specify any others:
External factors	yes	no
soap
perfume
wool
laundry detergent
hard water
Specify any others:

 

no

yes

if yes, specify

Among the parents?	no	yes
Among siblings?	no	yes

 

Is there a family background of allergies?

no

yes

Among the parents?

no

yes

	if yes, specify the type of allergy:	yes	no
	eczema
	asthma
	allergic rhinitis
	pruritis
	food intolerance
	other
Among the Siblings? no yes
if yes, specify number of allergic brothers and/or sisters:
	and the type of allergy:	yes	no
	eczema
	asthma
	allergic rhinitis
	pruritis
	food intolerance
	other

no

yes

If yes, check appropriate box:

parents pharmacist general practitioner pediatrician dermatologist

 
Have any products already been used?

no yes

based on the parents’ personal advice: no yes

based on the advice of a healthcare professionals: physician pharmacist

based on the recommendation of a specific document: brochure magazine internet