| 1. Over the last week, how itchy, sore, painful or stinging has your skin been? | 3 | 1 | 3 | 1 |
| 2. Over the last week, how embarrassed or self conscious have you been because of your skin? | 3 | 1 | 3 | 1 |
| 3. Over the last week, how much has your skin interfered with you going shopping or looking after your home or garden? | 2 | 1 | 3 | 1 |
| 4. Over the last week, how much has your skin influenced the clothes you wear? | 3 | 2 | 3 | 1 |
| 5. Over the last week, how much has your skin affected any social or leisure activities? | 2 | 0 | 3 | 0 |
| 6. Over the last week, how much has your skin made it difficult for you to do any sport? | 3 | 2 | 2 | 0 |
| 7. Over the last week, has your skin prevented you from working or studying?** | 3 | 0 | 3 | 0 |
| If "No", over the last week how much has your skin been a problem at work or studying? | - | 0 | - | 0 |
| 8. Over the last week, how much has your skin created problems with your partner or any of your close friends or relatives? | 0 | 0 | 0 | 0 |
| 9. Over the last week, how much has your skin caused any sexual difficulties? | 0 | 0 | 0 | 0 |
| 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? | 2 | 0 | 2 | 0 |
| Total | 21 | 7 | 22 | 4 |