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 Name

Last Name

DOB (dd/mm/yyyy)

Post Code

1. Over the last week, how itchy, sore, painful, or stinging has your skin been?

2. Over the last week, how embarrassed or self conscious have you been because of your skin?

3. Over the last week, how much has your skin interfered with you going shopping or looking after your home or garden?

4. Over the last week, how much has your skin influenced the clothes you wear?

5. Over the last week, how much has your skin affected any social or leisure activities?

6. Over the last week, how much has your skin made it difficult for you to do any sport?

7. Over the last week, has your skin prevented you from working or studying?

If "No", over the last week how much has your skin been a problem at work or studying?

8. Over the last week, how much has your skin created problems with your partner or any of your close friends or relatives?

9. Over the last week, how much has your skin caused any sexual difficulties?

10. 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?


Please check you have answered EVERY question. Thank you.




© A Y Finlay, G K Khan April 1992 www.dermatology.org.uk