When do you most likely skin-pick? (Tick all that apply)
If I'm bored
If I'm procrastinating
If I'm over-thinking
If I'm feeling anxious
Before a social event or occasion
After a social event or occasion
Whilst sleeping
When concentrating
Out of 10, how much does skin-picking affect your quality of life? (1 = not at all and 10 = an extremely considerable amount)
1
2
3
4
5
6
7
8
9
10
Out of 10, how much does skin-picking affect your self-confidence? (1 = not at all and 10 = an extremely considerable amount)
1
2
3
4
5
6
7
8
9
10
Are you aware of any family members or friends that struggle with a body-focused repetitive behavior such as dermatillomania?
Yes I am
No I'm not
How often do you skin pick?
Very occasionally
Once or twice per week
Once or twice per day
Multiple times per day
Where do you commonly skin pick? (Tick all that apply)
Scalp
Face and neck
Shoulders and chest
Arms and hands
Back
Legs and thighs
Feet
Buttox
Pubic area
None of the above
How long do you skin-picking episodes usually last for?
1 minute or less
Up to 5 minutes
Up to 10 minutes
Up to 20 minutes
Up to 30 minutes
Up to 1 hour
Over 1 hour
Have you mentioned your skin-picking to a loved one?
Yes I have
No I haven't
If you answered yes, have you received any support from a loved one?
Yes I have
No I haven't
I have not mentioned my skin-picking to a loved one
Have you been diagnosed with dermatillomania?
Yes I have
No I haven't been diagnosed but I believe I may have it
Have you also been diagnosed with body dysmorphia or believe you may have it?
Yes I have
No I haven't
No I haven't been diagnosed but I believe I may have it
Have you spoken to your doctor or other medical professional regarding your skin-picking?
Yes I have
No I haven't
If you answered no to the previous question, why do you believe that is?
I feel too ashamed or embarrassed
I don't think they would believe me
Other reason
I did speak to my doctor/medical professional
Have you taken topical prescription medication to help treat your skin?
Yes I have
No I haven't
Have you taken prescription medication to help your compulsive skin-picking?
Yes I have
No I haven't
Have you taken Roaccutane (Isotretinoin) to help your compulsive skin-picking?
Yes I have
No I haven't
If you answered yes, do you believe it helped your skin-picking?
Yes I do
No I don't
I have not taken Roaccutane
Have you been referred to a therapist to receive Cognitive Behavioral Therapy aka CBT?
Yes I have
No I haven't
If the answer was yes, did you find CBT to be useful?
Yes I did
No I didn't
I haven't tried CBT
Do you suffer from general anxiety?
Yes I do
No I don't
Do you suffer from social anxiety?
Yes I do
No I don't
Do you suffer from depression?
Yes I do
No I don't
Do you suffer from any other mental health condition not already mentioned?
Yes I do
No I don't
Do you believe there is enough help and support available for your skin-picking?
Yes I do
No I don't
I'm unsure
Do you wish there were a wider amount of research, help and support available for you?
Yes I do
No I don't
If more help and support were available, would you use it?
Yes I would
No I wouldn't
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