Questionnaire - Page 7 of 9 (1014 maximum possible questions)

Last updated: May 05, 2008

SYMPTOMS: SKIN: GENERAL
713.	Do you have calluses on your heels and, if so, are they cracked?	No / don't know Light callus without significant cracking Light callus with cracking Thick callus without significant cracking Thick callus, cracked
714.	Do you have a problem with cracking skin, typically on the fingers, toes or in skin creases? Do not include cracked heel calluses.	No / don't know Occasionally / moderate Often / severe
715.	Do you have small bumps on the backs of your arms?	No / don't know Yes, some/minor Diagnosed with keratosis pilaris Yes, many/definite
716.	What is your skin color prior to suntan, compared to others of your race, or family members?	Significantly lighter/paler A little lighter/paler Average / don't know A little darker/redder Significantly darker/redder
717.	What is your facial coloring prior to suntan, compared to others of your race, or family members?	Noticeably pale Slightly pale Average / don't know Slightly dark Noticeably dark, pink, flushed or ruddy
718.	Not counting blushing during embarrassing situations, do you experience facial blushing, flushing or redness more frequently or intensely than would be considered normal?	Don't know / I think I'm average No, definitely not Mild / occasionally Moderate / sometimes Major / often
719.	Does your skin seem to have a more yellowish (jaundiced) tone than previously? It may help to look at untanned areas.	Don't know No Probably Definitely
720.	Skin moistness. Without moisturizer, is your skin...?	Very dry A bit dry Average / don't know A bit oily/moist Definitely oily/moist
721.	Does your skin tend to itch often, perhaps worse at night?	No / don't know Moderately Severely
722.	Do you have a burning sensation on your skin?	Don't know No, definitely not Mildly / occasional Moderately / sometimes Severely / frequently
723.	Do you have a sensation of bugs crawling under or on top of your skin?	Don't know No Mildly / occasionally Moderately / sometimes Definitely / frequently
724.	Do you perspire/sweat...?	Very little / not easily Less than average About average / don't know More than average Lots / easily
725.	Do your palms sweat excessively?	No / don't know Moderate problem of less than 1 year Moderate problem of more than 1 year Major problem of less than 1 year Major problem of more than 1 year
726.	Does your perspiration/sweat have a strong odor?	Don't know No Somewhat Definitely
727.	Do you bruise easily?	No / don't know Mildly Moderately Seriously Severely - I usually have bruises somewhere
728.	Do you have palms and fingertips that are more red than average?	No / don't know Somewhat Definitely
729.	Is your skin temperature . . . ?	Very cold Colder than average Average / don't know Warmer than average Very warm
730.	Is your skin thickness . . . ?	Very thin / fragile Thinner than average Average / don't know Thicker than average Very thick / tough
731.	Is your skin yellow-tinged?	No / don't know Somewhat Definitely
732.	Beyond the questions already asked, do you have ANY skin problems? This would include diagnosed conditions like acne, eczema, psoriasis, dandruff, polyps, spots, rashes, infections, MRSA, etc..	Don't know No Yes    More questions later...
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SYMPTOMS: HAIR
733.	Do you have less hair or a bald patch on the front/side aspect of your lower leg(s)?	No / don't know Yes
734.	Have you had a recent change in body hair quantity?	Much recent loss Some recent loss No / don't know Some recent gain Much recent gain
735.	Do you have an urge or habit of pulling or plucking hairs from your body beyond the removal of selected hairs for cosmetic reasons?	Don't know No Yes, from time to time Yes, I habitually pull hairs out Yes, I habitually pull hairs out and eat them
736.	Do you have less pubic or underarm hair growth than previously?	I can't tell / don't know No, quantity is the same Yes, the quantity has decreased somewhat Yes, the quantity has decreased substantially
737.	Do you have male pattern hair loss? Male pattern hair loss (MPHL) is a common condition in which men, and sometimes women, experience a receding hairline and/or balding on the top of the head.	No / don't know Mildly / frontal loss only Moderately / partial loss on top only Moderately / complete loss on top only Severely / nearly or totally bald
738.	Is your scalp hair falling out, but not as part of male pattern baldness?	Don't know Normal loss History of serious loss / alopecia areota Moderate loss Much loss
739.	If you suffer from male pattern hair loss, at approximately what age did it start progressing significantly?	Not applicable / don't know 25 or under 26 to 35 36 to 45 Over 45
740.	How oily is your hair?	Dry Average / not applicable / don't know Oily
741.	Apart from graying, what color tone is or was the hair on your head?	Very light Light Average / not applicable / don't know Dark Very dark
742.	If you have gray hair, choose the answer that best describes the graying process in your case. Hair graying is both genetic and age-related.	I have no hair / no gray hair / don't know It retained its natural color longer than expected It has grayed normally for my age and race Somewhat prematurely (over half gray before 45) Very prematurely (over half gray before 35)
743.	Aside from male pattern baldness, how dense is the hair on your head?	Very sparse Somewhat sparse Average / not applicable / don't know Dense/abundant
744.	How strong are individual hairs from your head?	Brittle / break easily Somewhat brittle Normal / durable / don't know
745.	How thick are individual hairs on your head?	Thin / fine Average / don't know Thick
746.	How fast does your scalp hair grow? Hair normally grows about 1/2 inch (1.25cm) per month or 6 inches (15cm) per year.	Very slowly Slowly Average / don't know Quickly Very quickly
747.	How wavy is your hair naturally?	It is straight "Average" / don't know It is wavy / curly
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SYMPTOMS: NAILS
748.	Do your fingernails have white spots on them that are not due to nail trauma/injury?	No / don't know A few Several
749.	Do you have any white areas (not spots) on your nails that are not due to nail injury/trauma?	No / don't know Pink at the base, turning white towards the ends 80% or more of nail beds are white, including base White lines from side to side, do not move White lines from side to side, move as nails grow
750.	Are (parts of) your nails any unusual color other than white?	No / don't know Green Blue and brown Black / somewhat brown
751.	Do you experience inflamed cuticles (the skin over the base of your nails)?	No / don't know Occasionally / moderately Often / severely
752.	Do you suffer from hangnails/agnails (painful swelling around the fingernails or toenails) or ragged cuticles (occurring when cuticle or skin surrounding the nail is damaged or torn)?	No / don't know Occasionally / moderate Often / severe
753.	Are your fingernails brittle - do they chip, peel or break easily?	Don't know No Somewhat Very
754.	Do your fingernails have ridges or grooves across them (from side to side)?	No / don't know A few / minor Many / pronounced
755.	Do your fingernails curve backward like little spoons?	Don't know No A little Definitely
756.	Do you have increased roundness of finger and toe tips and nails that look like upside down spoons? This is called clubbing and can be seen here.	Don't know No Possibly Definitely with some digits Definitely, both fingers and toes
757.	How fast do your fingernails grow? Normal growth is 0.8 inches (2cm) per year but this can be hard to estimate.	Very slowly Slowly Average / don't know Quickly Very quickly
758.	Are your toenails distorted/deformed?	No / don't know Probably/minor episode now resolved Major episode now resolved Current minor problem Current major problem
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HABITS / ACTIVITIES / TENDENCIES
779.	On average, how often do you use a cell phone? This is only when the phone is actually held up to your ear, not when using an ear bud or using 'hands-free', such as in a car.	Don't know Never/Rarely Less than 30 minutes a day 30 to 60 minutes a day Over an hour each day
780.	Do you exercise aerobically for a minimum of 20 minutes or more?	Don't know No / rarely 1-2 times per week 3-4 times per week At least 5 times per week
781.	Aside from specific exercise sessions, for approximately how many hours each week are you strenuously active? This includes activities / jobs that involve lifting/carrying heavy objects, digging, running, etc..	Don't know None 1 to 5 6 to 10 More than 10
782.	If you are not getting as much exercise as you should (at least three 20-minute sessions of aerobic exercise per week), what is the reason for this? Work-related activity involving raised heart rate and sweating qualifies as exercise.	Not applicable (I do exercise enough) / don't know I just don't feel like it I don't have the time Physical problems prevent me Disease / illness prevents me
783.	When you exercise (run, walk fast, cycle, etc.), do you easily get a 'stitch' in your side?	Don't know No, never Rarely Regularly, but under half the time Most of the time
784.	Excessive exercise. Is it likely that others might think that you exercise compulsively?	Don't know No, definitely not Possibly (?) Yes, definitely
785.	Do you practice Yoga?	Never / don't know Once per month or less Once per week or less A few times per week At least daily
786.	Have juice or water fasts helped you? Please only count those that have been 5 days or longer.	I have never tried one / don't know No, there has been no noticable benefit They may help a little They sometimes help significantly They always help significantly
787.	When was the last water or juice fast you experienced? This would be any water fast of longer than 5 days or a juice fast of longer than approximately 10 days.	Not applicable / don't know Over a year ago Within the last year Within the last 3 months Within the last month
788.	Do you use chewing tobacco?	No / don't know Minor use in the past only Major use in the past only Minor current use / occasionally Major current use / frequently
789.	Second-hand smoke. Within the last eight years, roughly how much time have you spent in smoked-filled environments? Heavy exposure is defined as being in a room with visible smoke/haze for more than 4 hours per day.	Don't know None / minimal 1-4 years of light exposure 5-8 years of light exposure or 1-4 years heavy 5-8 years of heavy exposure
790.	Have you smoked tobacco within the last 8 years?	Don't know No Yes, I have smoked More questions later...
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