| 1. Over the last week, how itchy, sore, painful or stinging has your skin been? | Very much | A little | Not at all |
| 2. Over the last week, how embarrassed or self conscious have you been because of your skin? | Very much | A little | A little |
| 3. Over the last week, hou much has your skin interfered with you going shopping or looking after your home or garden? | Very much | A lot | A little |
| 4. Over the last week, how much has your skin influenced the clothes you wear? | Very much | A little | A little |
| 5. Over the last week, how much has your skin affected any social or leisure activities? | Very much | A little | A little |
| 6. Over the last week, how much has your skin made it difficult for you to do any sport? | Very much | A lot | A little |
| 7. Over the last week, has your skin prevented you from working or studying? | No | No | No |
| If "No", over the last week how much has your skin been a problem at work or studying? | A lot | A little | A little |
| 8. Over the last week, how much has your skin created problems with your partner or any of your close friends or relatives? | A lot | A lot | A little |
| 9. Over the last week, how much has your skin caused any sexual difficulties? | Very much | A lot | A little |
| 10. Over the last week, how much of a problem has the treatment for your skin been, for example by making your home messy, or by taking up time? | Very much | A little | A little |
| Total Score | 28 | 14 | 9 |