Rosacea Diary Booklet

Rosacea Diary Form

Date: ____________________
 

Check the weather conditions you were exposed to today:

_____ Sunny

_____ Windy

_____ Cloudy

_____ Humid

_____ Hot

_____ Cold

_____ Mild

_____ Dry

 

 

Check the foods and beverages you consumed today:

_____ Spicy foods

List: _________________________________

 

_____________________________________

_____ Alcohol

List: _________________________________

_____ Heated beverages

List: _________________________________

_____ Other

List: _________________________________

 

_____________________________________


 

 

Check the activities you experienced today:

_____ Emotional stress

Describe: _____________________________

 

_____________________________________

_____ Heavy exercise

Describe: _____________________________

_____ Hot bath/shower

Describe: _____________________________

_____ Indoor heat

Describe: _____________________________

_____ Other

Describe: _____________________________


 

 

List any products you used on your face:

__________________________________________________________

 

 

 

 

Did you comply with your medical therapy today?

_____ Yes

_____ No

 


 

 

What is the condition of your rosacea today?

_____ No flare-up

_____ Mild flare-up

_____ Severe flare-up


 

 

 

 

 

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