Also available in German / auch auf deutsch vorhanden!

Erlanger Atopy Questionnaire

Calculates your personal 'Atopy-Score', i.e. calculates a probability that you suffer or will suffer from atopic eczema (Neurodermatitis).

All data will for a study be stored anonymously and will be treated confidentially. After filling in the questionnaire you will get an immediate scoring.
Please answer all questions, without leaving out any items, even if one or another question doesn't fit for you. Always choose the answer best fitting for you.

Estimated time needed to complete the questionnaire: 5-6 minutes

For whom are you filling in this questionnaire: :

Age: Month of birth:

Sex
male
female

Height (cm): (in centimeter - 1 inch = 2,5 centimeters)
Weight (kg): (in kilogram - multiply pounds by .45 to get kg)

Highest school degree of the parents
Mother:
Father:

Do you have or did you have eczema in elbow flexures and/or hollow of the knees?
no, not that I am aware of
yes. The eczema first appeared at the age of

Do you know, if the doctor diagnosed you with having Neurodermatitis (=atopic eczema, endogenous eczema) ?
no, not that I am aware of
I am not sure, might be
yes.

Do you have or did you have chronic rhinitis (congesteted or running nose without having a flu) or seasonal rhinitis?

no
yes, not seasonal (the whole year)
yes, seasonal (e.g. especially in springtime)
First appeared at the age of years.

Do you have or did you have often inflamed eyes (conjunctivitis)?

no
yes
First appeared at the age of years.

Do you have or did you have Asthma?

no
yes
First appeared at the age of years.

Further diseases and health problems you are suffering from:

Alopecia areata (circumscribed hair-loss): yes no
Warts: very often relatively often rarely never

How many warts do you have at the moment:

Herpes labialis ("cold sores"): very often relatively often rarely never

Migraine (headaches with nausea, lasting about one day):
Yes No

How many times per month do you have migraine: per month

Other diseases:

Under which conditions/ circumstances did you grow up (mainly) (age 0-10):
(leave blank if no uniform answer possible, e.g. in the case of frequent moves)

Land:		other, namely: car plate country code
Smoking of mother during pregnancy:	mother did smoke during pregnancy	mother did not smoke during pregnancy	don't know
Grew up with smokers in household:	Smokers among the members of the household (eg father/mother)	no smokers
Grew up with environmental pollution:	Large city or industrial area or high traffic area	Little environmental pollution (e.g. rural region)
Living conditions during age 0-10:	Old building (high ceiling)	Tenement house	other (e.g. one-family house etc.)
Home heating during age 0-10:	oil heating	no oil heating
Domestic animals during age 0-10:	Domestic animals (with hairs, living inside the rooms, eg cats, dogs, rabbit, guinea pig)	no hairy animals inside the rooms
Psyche:	I memorize my childhood mainly as good and stress-free	My childhood is characterized by stress-factors (e.g. divorce of parents)

Does or did anyone from your first degree family members have eczemas?

Father:
Yes
No
Mother:
Yes
No
Brother:
Yes
No Sister:
Yes
No

Does or did anyone from your first degree family members have Asthma or chronic / seasonal rhinitis?

Father:
Yes
No
Mother:
Yes
No
Brother:
Yes
No Sister:
Yes
No

As a baby, did you have so called milk scurf (itching and scratched weeping lesions) ?

No
Yes

Do you suffer from itching, which deteriorates when sweating?

No
Yes

Is wool on the skin very uncomfortable?

No
Yes

Do you develop easily allergies against metals (nickel, piercing, watches) on the skin?

No, no allergy
Yes, I am sensitive against metals

Are you suffering from photophobia (increased sensitivity against bright light)?

No
Yes

Do you have very dry skin?

No
Yes

Do you sometimes have rhagades (fissures, cracks in the skin) behind the earlobe?

No
Yes

Did you ever have little, itching blisters on the palms of your hands (or feet) or fingers/toes, filled with clear fluid [so called dyshidrotic eczema]?

No
Yes

Do you have isolated, some scalding spots on arm or shoulder or other skin parts, which possibly in summer when the rest of the skin is tanned impose as some lighter spots (so-called Pityriasis alba) ?

No
Yes

Do you sometimes have very dry, fissured finger- or toe-tips?

No
Yes

Did you ever have had a nipple eczema (also men)?

No
Yes

Do you sometimes have inflammation with redness, burning and little skin fissures in the angle of the mouth (so-called Perlèche)?

No
Yes

Do you have a hyperlinearity of the palms of your hands (with deepening of creases)?

No
Unclear
Moderate
Strong

Are your lateral eye brows thinned or absent?

No
Unclear
Moderate
Strong

Do you have greyish-brownish, "dirty" looking discoloration(s) in the neck area?

No
Unclear
Moderate
Strong

Do you have or have you had numerous follicular skin-colored pinhead-sized ceratoses (affected skin feels like a grater. Removal of the keratoses by scratching often reveals a rolled-up hair)?

No
Unclear
Moderate
Strong

Do you have a so-called double folds of the lower eyelids?

No
Unclear
Moderate
Strong

If you strike (not very strongly) with the back end of a pen (or something similar) over the skin (e.g. of your forearms) and wait 40 seconds, you see...
nothing
a linear redness
a white line

Do you often have cold (possibly also blueish) fingers, without the environmental temperature being cold?
No
Yes