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Rosacea Diary Checklist You can complete the highlighted fields on this form online and then print the form for easy reference. Only text that is visible on the form is printed scrolled text will not print* Any text you enter into these fields will be cleared when you close the form you cannot save it. Use this form at the end of each day to identify your personal rosacea triggers. Date Check the weather conditions you were exposed to today. Sun Heat Cold Humidity Wind Check the foods beverages and other items you ve had today. Spicy foods List Alcohol Hot beverages Fruits Dairy products Vegetables Drugs Other Check the conditions and activities you experienced today. Emotional stress Describe Physical exertion Describe Hot bath/sauna Warm room temperatures Medical condition List flushing chronic cough hot flashes fever etc* Check the substances you came in contact with today. Skin care products Cosmetics Soap Perfume Aftershave Shampoo Household What is the condition of your rosacea today No flare-up Mild flare-up Severe flare-up Did you comply with your medical therapy today Yes No Adapted with permission from the National Rosacea Society http //www. rosacea*org. 1995-2011 Healthwise Incorporated* Healthwise Healthwise for every health decision and the Healthwise logo are trademarks of Healthwise Incorporated* This information does not replace the advice of a doctor. Only text that is visible on the form is printed scrolled text will not print* Any text you enter into these fields will be cleared when you close the form you cannot save it. Use this form at the end of each day to identify your personal rosacea triggers. Date Check the weather conditions you were exposed to today. Use this form at the end of each day to identify your personal rosacea triggers. Date Check the weather conditions you were exposed to today. Sun Heat Cold Humidity Wind Check the foods beverages and other items you ve had today. Spicy foods List Alcohol Hot beverages Fruits Dairy products Vegetables Drugs Other Check the conditions and activities you experienced today. Sun Heat Cold Humidity Wind Check the foods beverages and other items you ve had today. Spicy foods List Alcohol Hot beverages Fruits Dairy products Vegetables Drugs Other Check the conditions and activities you experienced today. Emotional stress Describe Physical exertion Describe Hot bath/sauna Warm room temperatures Medical condition List flushing chronic cough hot flashes fever etc* Check the substances you came in contact with today. Emotional stress Describe Physical exertion Describe Hot bath/sauna Warm room temperatures Medical condition List flushing chronic cough hot flashes fever etc* Check the substances you came in contact with today. Skin care products Cosmetics Soap Perfume Aftershave Shampoo Household What is the condition of your rosacea today No flare-up Mild flare-up Severe flare-up Did you comply with your medical therapy today Yes No Adapted with permission from the National Rosacea Society http //www.

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