Rosacea Diary Booklet
Rosacea Diary Form
Date: ____________________
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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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Contact Us
- Phone:
- 1-888-NO-BLUSH
- Email:
- rosaceas@aol.com
196 James St.
Barrington, IL 60010
Our Mission
The National Rosacea Society is a 501(c)(3) nonprofit organization whose mission is to improve the lives of people with rosacea by raising awareness, providing public health information and supporting medical research on this widespread but little-known disorder. The information the Society provides should not be considered medical advice, nor is it intended to replace
consultation with a qualified physician. The Society does not evaluate, endorse or recommend any particular medications, products, equipment or treatments. Rosacea may vary substantially from one patient to another, and treatment must be tailored by a physician for each individual case. For more information, visit About Us.