Rosacea Awareness Checklist

You can print this form for easy access to list potential triggers when you have a Rosacea flare-up.
Use the diary every day for several weeks to keep track of the factors that may be causing your symptoms of Rosacea.
Awareness of triggers is a critical step in treating the symptoms

  

This page is made to print out and use to list potential triggers when you have a Rosacea flare-up.

Date____________

• Which weather conditions were you exposed to today

  ____ Sun  ____ Heat  ____ Cold  ____ Humidity   ____ Wind

List the foods, beverages, and other items you've had today.

____ Spicy foods	List:__________________________________________________________
____Alcohol	List:__________________________________________________________
____Hot beverages	List:__________________________________________________________
____ Fruits	List:__________________________________________________________
____Diary products	List:__________________________________________________________
____Vegetables	List:__________________________________________________________
____ Medication	List:__________________________________________________________
____ Other	List:__________________________________________________________

List the conditions and activities you experienced today

____ Emotional Stress	List:__________________________________________________________
____ Physical Exertion	List:__________________________________________________________
____ Hot bath / sauna	List:__________________________________________________________
____ Warm room      temperatures	List:__________________________________________________________
____ Medical condition	List:__________________________________________________________ (flushing, hot flashes, fever, chronic cough, etc.)
____ Other	List:__________________________________________________________

List the substances you came in contact with today

____ Skin Care       Products	List:__________________________________________________________
____ Shampoo	List:__________________________________________________________
____ Cosmetics	List:__________________________________________________________
____ Soap	List:__________________________________________________________
____ Perfume	List:__________________________________________________________
____ Aftershave	List:__________________________________________________________
____ Household Products	List:__________________________________________________________
____ Other	List:__________________________________________________________

What is the condition of your Rosacea today?

____ No flare-up    ____ Mild flare-up    ____ Severe flare-up

Did you comply with your skin care therapy today?

____ Yes      ____ No