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Hospital No:
Name:
Address:
1. Over the last week, how itchy, 'scratchy', sore or painful has your skin been?
Very much
Quite a lot
Only a little
Not at all
3. Over the last week, how much has your skin affected your friendships?
Very much
Quite a lot
Only a little
Not at all
5. Over the last week, how much has your skin trouble affected going out, playing or doing hobbies?
Very much
Quite a lot
Only a little
Not at all
7a. If school time: Over the last week, how much did your skin problem affect your school work?
Prevented school
Very much
Quite a lot
Only a little
Not at all
8. Over the last week, how much trouble have you had becuase of your skin with other people calling you names, teasing, bullying, asking questions or avoiding you?
Very much
Quite a lot
Only a little
Not at all
10. Over the last week, how much of a problem has the treatment for your skin beene?
Very much
Quite a lot
Only a little
Not at all
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Date:
CDLQI Score:
Age:
Diagnosis:
2. Over the last week, how embarrassed or self conscious, upset or sad have you been because of your skin?
Very much
Quite a lot
Only a little
Not at all
4. Over the last week, how much have you changed or worn different or special clothes/shoes because of your skin?
Very much
Quite a lot
Only a little
Not at all
6. Over the last week, how much have you avoided swimming or other sports because of your skin trouble?
Very much
Quite a lot
Only a little
Not at all
7b. If holiday time: How much over the last week has your skin problem interfered with your enjoyment of the holiday?
Very much
Quite a lot
Only a little
Not at all
9. Over the last week, how much has your sleep been affected by your skin problem?
Very much
Quite a lot
Only a little
Not at all
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