Information for Patients

Patient Diary Checklist

Use this form at the end of each day to identify your personal rosacea triggers.

Date: ____________________


Check the weather conditions you were exposed to today.
_____ Sun _____ Heat _____ Cold _____ Humidity _____ Wind


Check the foods, beverages and other items you ingested today.
_____ Spicy foods List: _________________________________
_____ Alcohol List: _________________________________
_____ Hot beverages List: _________________________________
_____ Fruits List: _________________________________
_____ Dairy products List: _________________________________
_____ Vegetables List: _________________________________
_____ Drugs List: _________________________________
_____ Other List: _________________________________
 

  
Check the conditions and activities you experienced today.
_____ Emotional stress Describe: _____________________________
_____________________________________
_____ Physical exertion Describe: _____________________________
_____________________________________
_____ Hot bath/sauna
_____ Warm room temperatures
_____ Medical condition List: _________________________________
(flushing, chronic cough, hot flashes, fever, etc.)
_____ Other List: _________________________________
 

  
Check the substances you came in contact with today.
_____ Skin care products List: _________________________________
_____ Cosmetics List: _________________________________
_____ Soap List: _________________________________
_____ Perfume List: _________________________________
_____ After shave List: _________________________________
_____ Shampoo List: _________________________________
_____ Household products List: _________________________________
_____ Other List: _________________________________