Your Name (required)
Your Email (required)
Your Phone Number
Is patient willing to come in for a screening visit?
Age of Patient
6 months old - 12 years12 years - older
When was atopic dermatitis diagnosed?
How much of patient's body is covered by eczema?
How red is patient's skin?
On average, how itchy does patient feel?
What kind of medication does the patient use currently?
Is that medication helping?
What kind of medication has the patient used previously?
Was that medication helpful?
If not, why was that medication discontinued?
If patient were to participate in a study, is there anything about research or medical visits that patient would prefer to avoid (ie. injections, very long visits)?
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