Daily Eczema Symptom and Treatment Tracking Sheet

Patient Information

Name: ___________________ Date Range: //___ to //___

Daily Symptom Assessment

Rate severity from 0 (none) to 5 (severe)

Morning Assessment

• Itching: ⃝ 0 ⃝ 1 ⃝ 2 ⃝ 3 ⃝ 4 ⃝ 5
• Redness: ⃝ 0 ⃝ 1 ⃝ 2 ⃝ 3 ⃝ 4 ⃝ 5
• Dryness: ⃝ 0 ⃝ 1 ⃝ 2 ⃝ 3 ⃝ 4 ⃝ 5
• Flaking: ⃝ 0 ⃝ 1 ⃝ 2 ⃝ 3 ⃝ 4 ⃝ 5

Evening Assessment

• Itching: ⃝ 0 ⃝ 1 ⃝ 2 ⃝ 3 ⃝ 4 ⃝ 5
• Redness: ⃝ 0 ⃝ 1 ⃝ 2 ⃝ 3 ⃝ 4 ⃝ 5
• Dryness: ⃝ 0 ⃝ 1 ⃝ 2 ⃝ 3 ⃝ 4 ⃝ 5
• Flaking: ⃝ 0 ⃝ 1 ⃝ 2 ⃝ 3 ⃝ 4 ⃝ 5

Treatment Log

Medications Applied

Morning: □ Moisturizer: ___________________ Time: _______ □ Topical medication: _____________ Time: _______ □ Oral medication: _______________ Time: _______

Evening: □ Moisturizer: ___________________ Time: _______ □ Topical medication: _____________ Time: _______ □ Oral medication: _______________ Time: _______

Trigger Exposure

Check all that apply today: □ Stress □ Heat/Sweating □ Dry air □ Allergens □ Irritating fabrics □ Other: ____________________

Notes

Sleep quality: □ Poor □ Fair □ Good Stress level: □ Low □ Medium □ High Additional observations: _______________________________

Bring this completed form to your next appointment