Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Part 1: Personal InformationYour NameFirstLastTo protect your privacy, this field is optional.Sex *--- 选择选项 ---MaleFemaleTransgender MaleTransgender FemaleUnspecifiedEmail *WhatsAppAge at Atopic Dermatitis Diagnosis *Part 2: Atopic Dermatitis CharacteristicsHEALTHCARE DETAILSDo you have an allergic constitution? *--- 选择选项 ---YESNO (Are you generally prone to allergic reactions?)Main Affected Areas (Multiple selections allowed)FaceNeckArmsLegsTorsoHandsOtherIf "Other" selected, please specifyCurrent Disease Severity (0-10) Current score: 3 0: No symptoms 2-3: Mild 5: Moderate 7-8: Severe 10: Extremely severePlease rate based on itch intensity, affected area size, and impact on daily life Itch Frequency *--- 选择选项 ---Rarely itchyOccasionally itchyFrequently itchyConstantly itchyImpact on Sleep *--- 选择选项 ---No impactMild impact (occasional waking)Moderate impact (waking several times a week)Severe impact (waking almost every night)Current Treatment MethodsPlease list any medications, skincare products, or other treatments you're currently using...How effective is your current treatment? *--- 选择选项 ---Very effectiveEffectiveModerateIneffectiveNot very effective How on Impact Additional Information or CommentsPlease provide any other information you consider important...Submit
