Share Your Story About Living With Eczema

Thank you for your interest in the National Eczema Association and for being willing to share this information about your eczema. This information helps us understand what is most important to people living with eczema, guides us in our work, and shapes our community’s voice.

First Name

Last Name

Address Line 1

Address Line 2

City

Country

State

Provinces

State/Province

Zip/Postal Code

Phone

Your interest in eczema? Select all that apply.

I am a health professionalI am the caregiver/partner/spouse of someone with eczemaI am the parent of a child with eczemaI have eczemaI work for a company with an interest in eczemaSupporter (Family Member, colleague, etc.)Other

What type of eczema do you have?

(select all that apply)

Atopic dermatitis

Hand eczema or hand dermatitis

Contact dermatitis

Seborrheic dermatitis

Dyshidrotic eczema

Nummular eczema

Neurodermatitis

Stasis dermatitis

I don’t know [Eczema type unknown]

Year you were diagnosed

Your gender

MaleFemale

What type of eczema does

the person you care for have?