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Survey

The Eczema Association is conducting a survey of Eczema sufferers in the hope of unlocking the mysteries of Eczema, and asks that you take the time to answer each question to the best of your ability.


YesNo

MaleFemale








YesNoUnsure

FoodWeatherStressGrassesSoapsDustEmotions


List the professionals people you have seen and if they were helpful or not

Treatments recommended

YesNo


YesNoUnsure

FatherAuntyUncleNephewNieceCousinGrandmotherGreat GrandmotherGrandfatherGreat Grandfather

MotherAuntyUncleNephewNieceCousinGrandmotherGreat GrandmotherGrandfatherGreat Grandfather

Brother/sSister/sOther (Half/Step)

YesNoUnsure

FatherAuntyUncleNephewNieceCousinGrandmotherGreat GrandmotherGrandfatherGreat Grandfather

MotherAuntyUncleNephewNieceCousinGrandmotherGreat GrandmotherGrandfatherGreat Grandfather

Brother/sSister/sOther (Half/Step)


NoMildSeasonalModerateControllableChronic


No Affect (easily controllable)ModeratelySeverely

YesNo

YesNo

YesNo

YesNo

YesNo

Please name the brands you use for the following:





BirdCatChickensCowDogDuckFishGuinea PigHorseKangarooMousePossumRabbitSheep





If you feel you have any information which could be of value to this survey please write the details here:


For Mother's of sufferers under the age of 10 we would appreciate the following information

BreechBleedingBlood PressureChicken PoxDiabetesFertilityFluid RetentionHyperemicInfectionsMiscarriageMorning SicknessPre-eclampsiaStressToxemia

NaturalCaesarean

PrematureFull TermLate

LightAverageHeavy

SmallAverageTall

YesNo

EpiduralFentinolGasNitrous OxideOxytocinParacetamolPethadineSleeping TabletsSyntocinon











JaundiceHepatitisKidney failure

ColicGastric Reflux




Privacy Act:

Information collected in this survey is for statistical purposes only and is stored in our electronic statistics program, which is password protected, and in our lockable filing cabinet. No identifying your information is distributed to a third party. You have the right to update and correct any personal information and the right to access any of your personal information held by the Eczema Association of Australasia Inc.