The aim of this questionnaire is to measure how much your skin problem has affected your life OVER THE LAST WEEK. Please tick one box for each question. First NameLast NameDOB (dd/mm/yyyy)Post Code1. Over the last week, how itchy, sore, painful, or stinging has your skin been? Very much A lot A little Not at all2. Over the last week, how embarrassed or self conscious have you been because of your skin? Very much A lot A little Not at all3. Over the last week, how much has your skin interfered with you going shopping or looking after your home or garden? Very much A lot A little Not at all Not relevant4. Over the last week, how much has your skin influenced the clothes you wear? Very much A lot A little Not at all Not relevant5. Over the last week, how much has your skin affected any social or leisure activities? Very much A lot A little Not at all Not relevant6. Over the last week, how much has your skin made it difficult for you to do any sport? Very much A lot A little Not at all Not relevant7. Over the last week, has your skin prevented you from working or studying? Yes No Not relevantIf "No", over the last week how much has your skin been a problem at work or studying? A lot A little Not at all8. Over the last week, how much has your skin created problems with your partner or any of your close friends or relatives? Very much A lot A little Not at all Not relevant9. Over the last week, how much has your skin caused any sexual difficulties? Very much A lot A little Not at all Not relevant10. Over the last week, how much of a problem has the treatment for your skin been, for example by making your home messy, or by taking up time? Very much A lot A little Not at all Not relevantPlease check you have answered EVERY question. Thank you. © A Y Finlay, G K Khan April 1992 www.dermatology.org.uk