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FORM 9 - Dermatology Life Quality Index

The aim of this questionnaire is to measure how much your skin problem has affected your life OVER THE LAST WEEK. Please check one box for each question.

Study ID number:

Patient number:

Participant's first name:

Last name:

Middle initial:

Please select study visit number:

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 past week, how much has your skin interfered with you going shopping or looking after your home or garden?

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

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

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

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

7a. If "No" to question 7, 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 of a problem 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?

Thank you for filling out this form. Before submitting, please be sure you have provided an answer to every question.