I agree to participate in this study* must provide value
Yes No Are you filling out the survey for yourself or your child? * must provide value
Myself My child Have you ever been told by a doctor or other health professional that you had eczema or atopic dermatitis? * must provide value
Yes No Has your child ever been told by a doctor or other health professional that they had eczema or atopic dermatitis?* must provide value
Yes No In the past 12 months, have you been told by a doctor or other health professional that you still had eczema or atopic dermatitis?* must provide value
Yes No In the past 12 months, has your child been told by a doctor or other health professional that they still had eczema or atopic dermatitis?* must provide value
Yes No How old are you?* must provide value
18 - 29 years
30 - 39 years
40 - 49 years
50 - 59 years
60 - 69 years
70 years and older
How old is your child?* must provide value
0 - 6 months 7 - 12 months 1 year 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 years or older How old were you when you were first diagnosed with eczema or atopic dermatitis?* must provide value
0 - 9 years
10 - 29 years
30 - 49 years
50 - 69 years
70 years and older
How old was your child when they were first diagnosed with eczema or atopic dermatitis?* must provide value
0 - 6 months 7 - 12 months 1 year 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 years or older In the past 12 months, how would you describe your eczema?* must provide value
Mild Moderate Severe In the past 12 months, how would you describe your child's eczema?* must provide value
Mild Moderate Severe Over the last week, on how many days has your skin been itchy because of the eczema?* must provide value
No days 1-2 3-4 5-6 7 days Over the last week, on how many nights has your sleep been disturbed because of eczema?* must provide value
No days 1-2 3-4 5-6 7 days Over the last week, on how many days has your skin been bleeding because of the eczema?* must provide value
No days 1-2 3-4 5-6 7 days Over the last week, on how many days has your skin been weeping or oozing clear fluid because of the eczema?* must provide value
No days 1-2 3-4 5-6 7 days Over the last week, on how many days has your skin been cracked because of the eczema?* must provide value
No days 1-2 3-4 5-6 7 days Over the last week, on how many days has your skin been flaking off because of the eczema?* must provide value
No days 1-2 3-4 5-6 7 days Over the last week, on how many days has your skin felt dry or rough because of the eczema?* must provide value
No days 1-2 3-4 5-6 7 days Over the last week, on how many days has your child's skin been itchy because of the eczema?* must provide value
No days 1-2 3-4 5-6 7 days Over the last week, on how many nights has your child's sleep been disturbed because of eczema?* must provide value
No days 1-2 3-4 5-6 7 days Over the last week, on how many days has your child's skin been bleeding because of the eczema?* must provide value
No days 1-2 3-4 5-6 7 days Over the last week, on how many days has your child's skin been weeping or oozing clear fluid because of the eczema?* must provide value
No days 1-2 3-4 5-6 7 days Over the last week, on how many days has your child's skin been cracked because of the eczema?* must provide value
No days 1-2 3-4 5-6 7 days Over the last week, on how many days has your child's skin been flaking off because of the eczema?* must provide value
No days 1-2 3-4 5-6 7 days Over the last week, on how many days has your child's skin felt dry or rough because of the eczema?* must provide value
No days 1-2 3-4 5-6 7 days Over the past week, how much has itch bothered you?
Over the past week, how much has itch bothered your child?
In the past year, what parts of your body were typically affected by eczema?* must provide value
None
The folds of the elbows
Behind the knees
In front of the ankles
Under the buttocks
Around the neck
Scalp
Ears
Behind the ears
Eyes are red, injected or stinging
Eyelids
Wrists
Forearms
Upper arms
Palms
Back of hands
Fingers
Nails
Back
Chest
Nipples
Trunk
Belly button or umbilicus
Groin or buttocks
Genitalia
Thighs
Legs
Feet
Please check all that apply
In the past year, what parts of your child's body were typically affected by eczema?* must provide value
None
The folds of the elbows
Behind the knees
In front of the ankles
Under the buttocks
Around the neck
Scalp
Ears
Behind the ears
Eyes are red, injected or stinging
Eyelids
Wrists
Forearms
Upper arms
Palms
Back of hands
Fingers
Nails
Back
Chest
Nipples
Trunk
Belly button or umbilicus
Groin or buttocks
Genitalia
Thighs
Legs
Feet
Please check all the apply
Over the last week, how severe do you think your child's eczema has been? None
Fairly good
Average
Severe
Extremely severe
Over the last week, how much has your child been itching and scratching? None
A little
A lot
All the time
Over the last week, what has your child's mood been? Happy
Slightly fretful
Very fretful
Always crying, extremely difficult
Over the last week, approximately how much time on average has it taken to get your child to sleep each night? Less than 1 h
1-2 h
3-4 h
5 h or more
Over the last week, what was the total time that your child's sleep was disturbed on average each night? Less than 1 h
1-2 h
3-4 h
5 h or more
Over the last week, has your child's eczema interfered with playing or swimming? None A little A lot Very much Over the last week, has your child's eczema interfered with your child taking part in or enjoying other family activities? None A little A lot Very much Over the last week, have there been problems with your child at mealtimes because of eczema? Not at all A little A lot Very much Over the last week, have there been problems with your child caused by the treatment? None A little A lot Very much Over the last week, has your child's eczema meant that dressing and undressing the child has been uncomfortable? None A little A lot Very much Over the last week, how much has your child having eczema been a problem at bath-time? None A little A lot Very much Over the last week, how much effect has your child having eczema had on housework, e.g. washing, cleaning? Not at all A little A lot Very much Over the last week, how much effect has your child having eczema had on food preparation and feeding? Not at all A little A lot Very much Over the last week, how much effect has your child having eczema had on the sleep of others in the family? Not at all A little A lot Very much Over the last week, how much effect has your child having eczema had on family leisure activities, e.g. swimming? Not at all A little A lot Very much Over the last week, how much effect has your child having eczema had on time spent on shopping for the family? Not at all A little A lot Very much Over the last week, how much effect has your child having eczema had on your expenditure, e.g. costs related to treatment, clothes, etc? Not at all A little A lot Very much Over the last week, how much effect has your child having eczema had on causing tiredness or exhaustion in your child's parents/carers? Not at all A little A lot Very much Over the last week, how much effect has your child having eczema had on causing emotional distress such as depression, frustration or guilt in your child's parents/carers? Not at all A little A lot Very much Over the last week, how much effect has your child having eczema had on relationships between the main carer and partner or between the main carer and other children in the family? Not at all A little A lot Very much Over the last week, how much effect has helping with your child's treatment had on the main carer's life? Not at all A little A lot Very much On average, how many hours of sleep do you get in a 24-hour period? 1 - 2
3 - 4
5 - 6
7 - 8
9 - 10
11 or more
On average, how many hours of sleep does your child get in a 24-hour period? 1 - 2
3 - 4
5 - 6
7 - 8
9 - 10
11 or more
During the past 30 days, for about how many days did you find yourself unintentionally falling asleep during the day? None
1 - 2
3 - 5
6 - 9
10 - 19
20 or more
During the past 30 days, for about how many days did your child unintentionally fall asleep during the day? None
1 - 2
3 - 5
6 - 9
10 - 19
20 or more
During the past 30 days, have you ever nodded off or fallen asleep, even just for a brief moment, while driving? Yes
No
I don't drive
During the past 30 days, did you have difficulties in school or at work because of sleepiness? No difficulty
Some difficulty
Very much difficulty
During the past 30 days, did your child have difficulties in school or at work because of sleepiness? No difficulty
Some difficulty
Very much difficulty
How many times did you go to an urgent care center or emergency department for your eczema? Once
Two or three times
Four to five times
Six or more times
How many times did your child go to an urgent care center or emergency department for their eczema? Once
Two or three times
Four to five times
Six or more times
What were the reasons for you going to an urgent care center or emergency department for your eczema? I had a severe flare
I had very bad itch
I ran out of my medications
I was unable to get an appointment with my regular doctor
I was unable to take off from work or school to see my regular doctor
I dont have insurance coverage
I dont have prescription medication coverage
I could not afford the copay or deductible for my eczema medications
I prefer the care that I get in the urgent care center or emergency department
other
What were the reasons for your child going to an urgent care center or emergency department for their eczema? He/she had a severe flare
He/she had very bad itch
He/she ran out of their medications
He/she was unable to get an appointment with their regular doctor
I was unable to take off from school to bring them to see their regular doctor
He/she doesn't have insurance coverage
He/she doesn't have prescription medication coverage
I could not afford the copay or deductible for his/her eczema medications
I prefer the care that he/she gets in the urgent care center or emergency department
other
How many times did you go to an urgent care center or emergency department for injuries or accidents? Once
Two or three times
Three to five times
Six or more times
How many times did your child go to an urgent care center or emergency department for injuries or accidents? Once
Two or three times
Three to five times
Six or more times
For what type of injury did you go to an urgent care center or emergency department? In a motor vehicle
On a bike or scooter
On a skateboard, skates, skis, horse, etc.
Pedestrian who was struck by a vehicle such as a car or bicycle
In a boat, train, or plane
Fall
Burned or scalded by substances such as hot objects or liquids, fire, or chemicals
Poisoning
Other
For what type of injury did your child go to an urgent care center or emergency department? In a motor vehicle
On a bike or scooter
On a skateboard, skates, skis, horse, etc.
Pedestrian who was struck by a vehicle such as a car or bicycle
In a boat, train, or plane
Fall
Burned or scalded by substances such as hot objects or liquids, fire, or chemicals
Poisoning
Other
What is your gender?* must provide value
Female Male What is your child's gender?* must provide value
Female Male What is your race (Choose all that apply) Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or other Pacific Islander
White
Multiracial / Other
What is your child's race (Choose all that apply) Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or other Pacific Islander
White
Multiracial / Other
What group best represents your Hispanic origin or ancestry?* must provide value
Not Hispanic/Spanish origin
Multiple Hispanic
Puerto Rican
Mexican
Mexican-American
Cuban/Cuban American
Dominican (Republic)
Central or South American
Other Latin American, type not specified
Other Spanish
Hispanic/Latino/Spanish, non-specific type or other
What group best represents your child's Hispanic origin or ancestry?* must provide value
