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Rosacea Diary Booklet
Rosacea Diary Form
Date: ____________________
Check the weather conditions you were exposed to today: |
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_____ Sunny |
_____ Windy |
_____ Cloudy |
_____ Humid |
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_____ Hot |
_____ Cold |
_____ Mild |
_____ Dry |
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Check the foods and beverages you consumed today: |
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_____ Spicy foods |
List: _________________________________ |
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_____________________________________ |
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_____ Alcohol |
List: _________________________________ |
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_____ Heated beverages |
List: _________________________________ |
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_____ Other |
List: _________________________________ |
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_____________________________________ |
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Check the activities you experienced today: |
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_____ Emotional stress |
Describe: _____________________________ |
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_____________________________________ |
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_____ Heavy exercise |
Describe: _____________________________ |
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_____ Hot bath/shower |
Describe: _____________________________ |
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_____ Indoor heat |
Describe: _____________________________ |
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_____ Other |
Describe: _____________________________ |
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List any products you used on your face: |
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__________________________________________________________ |
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Did you comply with your medical therapy today? |
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_____ Yes |
_____ No |
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What is the condition of your rosacea today? |
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_____ No flare-up |
_____ Mild flare-up |
_____ Severe flare-up |
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