Patient Name:____________________
Rosacea Questionnaire
SKIN FUNCTION AND SYMPTOMS
Do you have difficulty, with any of the following?
YES
NO
1. Does your facial skin cause you pain or discomfort?


2. Does your face skin itch?


3. Does your facial skin burn?


4. Does your facial skin get flaky or irritated?


5. Is your facial skin very sensitive to heat or cold?


6. Does your facial skin flush frequently or feel very warm or hot?


7. Is your facial skin sensitive to things you eat such as spicy foods,
chocolate, caffeine, etc…?


8. Do you have worsening redness and/or blood vessels on your face?


9. Do you avoid doing things you like because of how your skin feels?


10. Do you get embarrassed or uncomfortable around others because
people ask you what is wrong with your face?


OTHER TREATMENT
Have you:
YES
NO
1. Used prescription oral medication such as antibiotics for your Rosacea?


2. Used topical prescription medication for your Rosacea?


3. Used any other products for your Rosacea?


What have you used? ______________________________________________________
Laser treatments for Rosacea are elective procedure that may improve the comfort
and functioning of your facial skin. If your current treatment for Rosacea with
prescription medication is not improving your condition sufficiently and the only way
to try to obtain further improvement is with laser treatments, do you feel your skin
problem is bad enough to consider laser treatments now?
 YES
 NO
My physician has reviewed this questionnaire with me and has also discussed treatment
options including laser treatments, with me.
Patient Signature ______________________________ Date ________________