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
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