Eczema Symptom Score Test (Landing Page Version)

Eczema Symptom Score Test
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Name*
Email*
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1. Symptom Assessment

Rate each symptom you experience on a scale of 0 - 10 (0= Not affected, 10 = Severely Affected)

Skin*

Rows	0	1	2	3	4	5	6	7	8	9	10
Red/Inflamed
Itching
Dryness
Weeping
Hives
Rosacea
Acne
Psoriasis
Dandruff
Pimples/bumps on arms
TSW
Other

Skin Score

Gut*

Rows	0	1	2	3	4	5	6	7	8	9	10
Food Intolerances
Bloating
Gas
Abdominal Pain
Diarrhea
Constipation
Greasy stools
Undigested food in stools
Heartburn
Nausea
Bad breath
Loss of appetite

Gut Score

Nervous System*

Rows	0	1	2	3	4	5	6	7	8	9	10
Anxiety
Depression
Insomnia
Irritability
Chronic fatigue
High stress
Headaches
Brain Fog
Poor memory
Confusion
Fainting
Other

Nervous System Score

Immune*

Rows	0	1	2	3	4	5	6	7	8	9	10
Allergies
Asthma
Hay Fever
Congestion
Runny/itchy nose
Cough
Sneezing
Itchy/watery/dry eyes
Mouth Ulcers
Frequent Colds/flus
Slow wound healing
UTI's

Immune Score

Hormone*

Rows	0	1	2	3	4	5	6	7	8	9	10
Irregular periods
Heavy flow
Back pain
Pelvic Pain
Breast Tenderness
Mood swings
Loss of libido
Excessive thirst
Frequent Urination
“Hangry”
Food cravings
Mid afternoon crash

Hormone Score

Other*

Rows	0	1	2	3	4	5	6	7	8	9	10
Joint Pain
Muscle Pain
Other

Other Score
2. What have you tried to find relief?

Put the # of times you visited or used each method.

Health Care Providers*

Rows	# of times
Doc
Dermatologist
Acupuncture / TCM
Naturopath
Nutritionist / Dietician
Other

Health Care Providers Score

Creams / Meds*

Rows	# of different meds
Creams (OTC or medicated)
Creams (natural)
Antihistamines
Anti-inflammatory meds
Antibiotics
Immunosuppressants`
Other

Creams / Meds Score

Protocols / Testing*

Rows	# of times
Blood Work
Functional Testing
Detox / Cleanses / Juicing
Elimination Diets
Other Diets / Protocols
Supplements / Herbs
Other

Protocols / Testing Scores
3. Your Eczema Symptom Score
Submit your score below to see what
Severity Zone you are in...
Should be Empty: