Intake English - Mooy zonder eczeem

Mooy without eczema – Intake

Dear you,

How wonderful that I get to help you towards your eczema-free life. The first important step you’ve taken today. We’ve completed the blood test together, congratulations!

To better understand how your skin condition became the way it is, I would like to ask you to fill out this questionnaire for me.

With all the information we are collecting now, I can create a personal and effective action plan together with your blood test results. We will discuss this plan during our next appointment.

If you have any questions, feel free to ask via in**@********oy.nl

Kind regards, Susanne

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Your personal details

Name*

First name Last name

Address*

Street & number City Postal code

Email address*

Enter email address Confirm email address

Date of birth*

DD dash MM dash JJJJ

Telephone number*

GP*

Work/profession*

Questions about your eczema

Since when have you been experiencing the skin condition eczema?*

Are there other people in your family with eczema?*

Were you born by caesarean section?*

Can you tell me where you have eczema? Has it always been in the same place or does it change?*

Can you tell me when your eczema flares up and when it can be calm?*

Can you link the flare-up of your eczema to anything?*

For example, certain foods, use of specific creams, or weather conditions?

Do you suffer from extremely dry skin? Flakes, cracks in your hands and/or feet?*

Any other important remarks about your eczema?

Questions about your diet

How do you view your own eating habits? Are you eating healthy, or could this be improved?*

How often do you eat processed and packaged convenience foods made by a factory?*

For example, cookies, muesli bars, Sultana, breakfast bars, candy, chips, cake, etc.

How many dairy products do you consume per day in your diet? Can you describe which products these are?*

How often do you find gluten in your diet? Is it daily or weekly?*

Gluten can be found in bread, pasta, cookies, cake, crackers, candy, beer, sometimes in sauces, etc.

Do you (often) crave sugar? If yes, how often is this per week?*

Do you use protein shakes? If yes, how often do you consume them per day/week?*

How was food viewed in your household when you were growing up? Was everything always cooked with fresh ingredients, or was it more out of packets, boxes, and jars?*

How do you currently feel about your current eating habits?*

Any other important remarks about your diet?

Questions about your energy level

Are you a coffee drinker? If yes, how many cups of coffee do you drink on average per day?*

Do you need coffee to start your day?*

How long does it take you to fall asleep? Do you often wake up during the night and lie awake for a long time?*

How many hours do you sleep on average per night?*

Do you often wake up feeling tired? If yes, how often is this per week?*

How do you feel most days of the week? Stressed, tired, or maybe energetic and well-rested?*

What kind of physical activity do you do on an average day? Think of cycling, walking, climbing stairs, etc.*

Do you practice any sports? If yes, which sport? How often and for how long?*

Any other important remarks about your energy level?

Questions about your skincare

What skincare products are you currently using?*

How often do you apply these skincare products per day? And where do you apply each product on your skin?*

Have you recently changed your skincare products (a lot)? If yes, what have you used so far?*

Which specialist(s) have prescribed these skincare products?*

Are there any skincare products that you have purchased without a prescription? If yes, which ones are these and why did you buy them?*

Any other important remarks about your skincare?

Questions about your health

Can you describe your bowel movements? How often do you go to the toilet, and what do they look like? Do they have a solid form, or are they rather loose?*

Have you ever noticed blood in your stool? If yes, how often does this occur?*

Do you suffer from chronic gastrointestinal issues, such as constipation, diarrhea, bloating, or stomach cramps?*

Have you ever been diagnosed with an autoimmune disease, such as psoriasis, rheumatoid arthritis, or inflammatory bowel diseases?*

Have you been diagnosed with type 2 diabetes or high blood sugar? If yes, when was this diagnosed?*

Do you smoke cigarettes or cigars? If yes, how many cigarettes per day?*

How long have you been smoking cigarettes or cigars?*

Do you drink alcohol? If yes, how many glasses per week?*

How many glasses/liters of water do you drink on average per day?*

Do you suffer from thinning hair or brittle nails?*

Do you frequently experience tinnitus (ringing in the ears)?*

Have you recently had a blood test done by a doctor? If yes, can you share the results?*

Any other important remarks about your health?

Questions about your allergies/intolerances*

*Please note: Intolerance does not mean you have an allergy! You can still eat it without swelling of the tongue or experiencing difficulty breathing. Intolerance means that your immune system is activated every time you eat something that your body cannot properly digest, which can cause your eczema to flare up or worsen.

Are you (to the best of your knowledge) allergic to anything? If yes, which substances?*

Have the substances mentioned in answer A been tested by a general practitioner/dermatologist/allergy therapist?*

If yes, who performed the test and when?

Are you (to the best of your knowledge) allergic or intolerant* to any specific foods?*

If yes, which foods?

Have the allergies/intolerances* mentioned in answer C been tested by a general practitioner/dermatologist/allergy therapist?*

If yes, who performed the test and when?

Any other important remarks about your allergies/intolerances.

Questions about your medication, vaccination(s), and supplements

What medication are you currently taking?*

What medication have you recently used/ceased (short-term)?*

This could include chronic medication as well as one-time medication, such as painkillers or for cough issues.

Do you take supplements? If yes, which ones and why do you take them?*

Have these supplements been prescribed by a general practitioner/dermatologist/homeopath/allergy therapist? If yes, when was this?*

Are you open to temporarily taking supplements to reduce your eczema?*

Have you taken antibiotics at least once in the past 2 years or used them on your skin?*

Have you been vaccinated in the past 2 years? If yes, which vaccination(s)?*

Any other important remarks about your medication and supplements?

The last questions about your eczema

If you were to rate the following statements, what score would you give at this moment?

Please rate on a scale of 1 to 10. (Write your score in the box.)
- 1 means never
- 5 means often
- 10 means always.

Continuous eczema complaints*

Dry skin*

Frequent eczema flare-ups*

The itching is continuously present*

My eczema moves across my body*

Eczema affects my daily life*

What would you be willing to do to have less trouble with eczema? What could this mean for you?*

Privacy disclaimer
The personal data of clients are handled and secured by Gewoon Mooy with the utmost care.

The data will not be shared with third parties or used for any purposes other than those for which you provided them.
Under the General Data Protection Regulation (GDPR), when personal data is processed, the person concerned must be informed, and the purpose for which the data is being collected must be communicated, and consent must be given.

By signing, I agree that Gewoon Mooy may process my personal data according to the General Data Protection Regulation (GDPR) for the treatment of my eczema complaints.

I agree to the privacy policy and the terms and conditions above.

Mooy without eczema – Intake

Your personal details

Questions about your eczema

Questions about your diet

Questions about your energy level

Questions about your skincare

Questions about your health

Questions about your allergies/intolerances*

Questions about your medication, vaccination(s), and supplements

The last questions about your eczema

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