Hyperhidrosis Treatment Evaluation Questionnaire * 1. Please indicate the type(s) of excessive sweating condition that you have. Focal hyperhydrosis Gustatory hyperhidrosis None of the above, please specify in comment box below Specify other condition * 2. From which body region(s) do you sweat excessively? Rate the severity of the sweating for the affected region(s). Mild Moderate Severe Facial Facial Mild Facial Moderate Facial Severe Scalp Scalp Mild Scalp Moderate Scalp Severe Soles Soles Mild Soles Moderate Soles Severe Palms Palms Mild Palms Moderate Palms Severe Underarms Underarms Mild Underarms Moderate Underarms Severe Chest Chest Mild Chest Moderate Chest Severe Back Back Mild Back Moderate Back Severe Groin Groin Mild Groin Moderate Groin Severe Other, please specify below Other, please specify below Mild Other, please specify below Moderate Other, please specify below Severe Specify other region(s) * 3. Which treatment(s) have you tried in the PAST and how satisfied were you with its/their results? Not at all Somewhat satisfied Satisfied Very satisfied Topical over the counter antiperspirant Topical over the counter antiperspirant Not at all Topical over the counter antiperspirant Somewhat satisfied Topical over the counter antiperspirant Satisfied Topical over the counter antiperspirant Very satisfied Topical high strength antiperspirant Topical high strength antiperspirant Not at all Topical high strength antiperspirant Somewhat satisfied Topical high strength antiperspirant Satisfied Topical high strength antiperspirant Very satisfied Topical glycopyrrolate Topical glycopyrrolate Not at all Topical glycopyrrolate Somewhat satisfied Topical glycopyrrolate Satisfied Topical glycopyrrolate Very satisfied Iontophoresis Iontophoresis Not at all Iontophoresis Somewhat satisfied Iontophoresis Satisfied Iontophoresis Very satisfied Botox injections Botox injections Not at all Botox injections Somewhat satisfied Botox injections Satisfied Botox injections Very satisfied Alternative therapies (herbal, homeopathy, natural products) Alternative therapies (herbal, homeopathy, natural products) Not at all Alternative therapies (herbal, homeopathy, natural products) Somewhat satisfied Alternative therapies (herbal, homeopathy, natural products) Satisfied Alternative therapies (herbal, homeopathy, natural products) Very satisfied Oral medication Oral medication Not at all Oral medication Somewhat satisfied Oral medication Satisfied Oral medication Very satisfied Laser therapy Laser therapy Not at all Laser therapy Somewhat satisfied Laser therapy Satisfied Laser therapy Very satisfied Surgery Surgery Not at all Surgery Somewhat satisfied Surgery Satisfied Surgery Very satisfied Other, please specify below Other, please specify below Not at all Other, please specify below Somewhat satisfied Other, please specify below Satisfied Other, please specify below Very satisfied Specify other treatments * 4. Which treatment(s) are you CURRENTLY using and how satisfied are you with its/their results? Not at all Somewhat satisfied Satisfied Very satisfied Topical over the counter antiperspirant Topical over the counter antiperspirant Not at all Topical over the counter antiperspirant Somewhat satisfied Topical over the counter antiperspirant Satisfied Topical over the counter antiperspirant Very satisfied Topical high strength antiperspirant Topical high strength antiperspirant Not at all Topical high strength antiperspirant Somewhat satisfied Topical high strength antiperspirant Satisfied Topical high strength antiperspirant Very satisfied Topical glycopyrrolate Topical glycopyrrolate Not at all Topical glycopyrrolate Somewhat satisfied Topical glycopyrrolate Satisfied Topical glycopyrrolate Very satisfied Iontophoresis Iontophoresis Not at all Iontophoresis Somewhat satisfied Iontophoresis Satisfied Iontophoresis Very satisfied Botox injections Botox injections Not at all Botox injections Somewhat satisfied Botox injections Satisfied Botox injections Very satisfied Alternative therapies (herbal, homeopathy, natural products) Alternative therapies (herbal, homeopathy, natural products) Not at all Alternative therapies (herbal, homeopathy, natural products) Somewhat satisfied Alternative therapies (herbal, homeopathy, natural products) Satisfied Alternative therapies (herbal, homeopathy, natural products) Very satisfied Oral medication Oral medication Not at all Oral medication Somewhat satisfied Oral medication Satisfied Oral medication Very satisfied Laser therapy Laser therapy Not at all Laser therapy Somewhat satisfied Laser therapy Satisfied Laser therapy Very satisfied Surgery Surgery Not at all Surgery Somewhat satisfied Surgery Satisfied Surgery Very satisfied Other, please specify below Other, please specify below Not at all Other, please specify below Somewhat satisfied Other, please specify below Satisfied Other, please specify below Very satisfied Specify other treatments * 5. Please provide the most likely reason for discontinuing any of the above mentioned treatments (excluding surgery). Poor response/lack of efficacy 'Wearing off 'effect - loss of efficacy with time Side effects/difficult to tolerate Too expensive Difficulty complying with demands of treatment Topical over the counter antiperspirant Topical over the counter antiperspirant Poor response/lack of efficacy Topical over the counter antiperspirant 'Wearing off 'effect - loss of efficacy with time Topical over the counter antiperspirant Side effects/difficult to tolerate Topical over the counter antiperspirant Too expensive Topical over the counter antiperspirant Difficulty complying with demands of treatment Topical high strength antiperspirant Topical high strength antiperspirant Poor response/lack of efficacy Topical high strength antiperspirant 'Wearing off 'effect - loss of efficacy with time Topical high strength antiperspirant Side effects/difficult to tolerate Topical high strength antiperspirant Too expensive Topical high strength antiperspirant Difficulty complying with demands of treatment Topical glycopyrrolate Topical glycopyrrolate Poor response/lack of efficacy Topical glycopyrrolate 'Wearing off 'effect - loss of efficacy with time Topical glycopyrrolate Side effects/difficult to tolerate Topical glycopyrrolate Too expensive Topical glycopyrrolate Difficulty complying with demands of treatment Iontophoresis Iontophoresis Poor response/lack of efficacy Iontophoresis 'Wearing off 'effect - loss of efficacy with time Iontophoresis Side effects/difficult to tolerate Iontophoresis Too expensive Iontophoresis Difficulty complying with demands of treatment Botox injections Botox injections Poor response/lack of efficacy Botox injections 'Wearing off 'effect - loss of efficacy with time Botox injections Side effects/difficult to tolerate Botox injections Too expensive Botox injections Difficulty complying with demands of treatment Alternative therapies (herbal, homeopathy, natural products) Alternative therapies (herbal, homeopathy, natural products) Poor response/lack of efficacy Alternative therapies (herbal, homeopathy, natural products) 'Wearing off 'effect - loss of efficacy with time Alternative therapies (herbal, homeopathy, natural products) Side effects/difficult to tolerate Alternative therapies (herbal, homeopathy, natural products) Too expensive Alternative therapies (herbal, homeopathy, natural products) Difficulty complying with demands of treatment Oral medication Oral medication Poor response/lack of efficacy Oral medication 'Wearing off 'effect - loss of efficacy with time Oral medication Side effects/difficult to tolerate Oral medication Too expensive Oral medication Difficulty complying with demands of treatment Laser therapy Laser therapy Poor response/lack of efficacy Laser therapy 'Wearing off 'effect - loss of efficacy with time Laser therapy Side effects/difficult to tolerate Laser therapy Too expensive Laser therapy Difficulty complying with demands of treatment Other, please specify below Other, please specify below Poor response/lack of efficacy Other, please specify below 'Wearing off 'effect - loss of efficacy with time Other, please specify below Side effects/difficult to tolerate Other, please specify below Too expensive Other, please specify below Difficulty complying with demands of treatment Specify other treatment and reason for discontinuation * 6. Have you in the past or are you currently treating with a combination of hyperhidrosis therapies. If yes, please list them below. If no, leave blank and go to question 8. First combination Second combination Third combination Fourth combination Fifth combination Add other combinations here * 7. Please provide the primary reason for using a combination of treatments. You can choose more than one answer. To increase efficacy of overall treatment (better response from two treatments as opposed to one) Treatment of several different body regions (e.g. iontophoresis for palms, solution for scalp) To avoid more expensive treatment To avoid more intrusive treatment (e.g. injections, surgery) Other, please specify below Specify other reason * 8. Please provide the names of all the treatments you have tried in the past or are currently taking. Topical antiperspirants Oral medications Alternate therapies * 9. Please provide further comments or observations related to treatment that may be beneficial to others with an excessive sweating condition. Done
