Please answer the following questions by checking the number which best describes you. Your clinician will total your score during the consultation.
If your score is: (0-3) (4-7) (8-11) (12-15) (16-19) (20 - 24)
Additional skin response questions:
Your answers on this form will help us understand your medical concerns and conditions. If you are uncomfortable with any question, do not answer it. Best estimates are fine, if you cannot remember
Prescription and non-prescription medicines, vitamins, home remedies, birth control pills, herbs: