Size
Skin Health Assessment
  Nutritional patterns  
Yes
No
  I regularly skip meals.  
  I eat 4 servings of fresh vegetables and fruit daily.  
  I eat protein with most meals.  
  I regularly shop in health food stores.  
  I mostly buy foods from center isles and frozen foods at the grocery store.  
  I consume processed or prepackaged food items regularly.  
  I eat less than least 15–20 grams of fiber each day.  
  I have consulted with a dietician or nutritionist for guidance.  
  I fully understand how to read ingredient labels.  
  I avoid hydrogenated oils and trans fats.  
  I regularly take nutritional supplements.  
  I consume alcohol each day.  
  I consume soft drinks each day.  
  I consume caffeine each day.  
  If I were to list 5 of my “comfort foods,” they would all include carbohydrates or sugars (sucrose, fructose, high-fructose corn syrup, glucose, galactose, maltose, lactose).
  
  I eat foods containing sugar, white flour, or white rice every single day.  
         
  Measures of self-care  
Yes
No
  I spend a minimum of 30 minutes outside for fresh air and sunshine daily.  
  I regularly wear sunblock to protect my skin from harmful rays.  
  I use relaxation techniques to decompress through the day.  
  I enjoy regular exercise at least 3 times per week.  
  I walk as much as I can in my daily activities.  
  I have an enjoyable social and family life.  
         
  I have visited the following type of healthcare provider for my skin disorder in the last year:
  Dermatologist    
  Primary care physician    
  Rheumatologist    
  None of the Above    
         
  What is your age?