Eczema Clarity Call
Please fill out this form in as much detail as possible. This will allow us to get the most out of our call - maximizing our time together and getting you the answers and clarity you need to heal your skin.
Full Name
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Email
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Phone Number
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Country Code
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Area Code
Phone Number
These calls are for adults (24 years old or older) dealing with eczema
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This is me. I am an adult with eczema.
This is NOT me. I am younger than 24 years old.
This is NOT me, I am filling this out for family or a friend.
On a scale of 1 - 10, how have your eczema symptoms been these past few months?
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Minimal
1
2
3
4
5
6
7
8
9
Severe
10
1 is Minimal, 10 is Severe
What symptoms are you currently experiencing?
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Redness
Itching
Dryness
Flaking
Dandruff
Bloating
Cramping/Pain
Reflux
Gas
Stress
Anxiety
Fatigue
Headache
Breast Tenderness (Women)
Back/Pelvic Pain (Women)
Moodiness (Women)
Heavy Flow (Women)
Blood Clotting (Women)
Cyclic Acne (Women)
Difficulty Sleeping
Poor Quality Sleep
Asthma
Allergies
Hay Fever
Infections
Other
What are you CURRENTLY working on to try to heal your skin and/or any other health conditions? (Diet/lifestyle, medications, creams/lotions, alternative therapies, etc.)
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Are you CURRENTLY using topical steroids (or any other form of steroid)?
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Yes
No, I stopped taking them *LESS THAN* 6 months ago
No, I stopped using them *OVER* 6 months ago
No, I've never used steroids
Are you currently pregnant or breastfeeding?
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Pregnant
Breastfeeding
Both
Neither
What’s happening in your life now that has you considering making changes to address your health and heal your rashes? (Please be as detailed as possible)
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Are you committed to taking action and intentionally creating the results that you want?
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Yes, I'm done being stuck and ready to financially invest in myself to heal my skin
No I can’t invest at all
Submit
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