DLQI Url 0% First Name Last Name Date of Birth (dd/mm/yyyy) Diagnosis 1. Over the last week, how itchy, sore, painful or stinging has your skin been? * Very much A lot A little Not at all Not relevant 10% 2. Over the last week, how embarrassed or self-conscious have you been because of your skin? * Very much A lot A little Not at all Not relevant 20% 3. Over the last week, how much has your skin interfered with you going shopping or looking after your home or garden? * Very much A lot A little Not at all Not relevant 30% 4. Over the last week, how much has your skin influenced the clothes you wear? * Very much A lot A little Not at all Not relevant 40% 5. Over the last week, how much has your skin affected any social or leisure activities? * Very much A lot A little Not at all Not relevant 50% 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 Not at all Not relevant 60% 7. Over the last week, has your skin prevented you from working or studying? * Yes No Not relevant If No, over the last week how much has your skin been a problem at work or studying? A lot A little Not at all 70% 8. Over the last week, how much has your skin created problems with your partner or any of your close friends or relatives? * Very much A lot A little Not at all Not relevant 80% 9. Over the last week, how much has your skin caused any sexual difficulties? * Very much A lot A little Not at all Not relevant 90% 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 lot A little Not at all Not relevant Your DLQI: Meaning of DLQI Scores 0 – 1 = no effect at all on patient’s life 2 - 5 = small effect on patient’s life 6 - 10 = moderate effect on patient’s life 11 - 20 = very large effect on patient’s life 21 - 30 = extremely large effect on patient’s life