SkinMed Questionnaire

1. If you are prone to flushing or blushing but do not believe you have rosacea, what do you think your risk of developing rosacea is?

Please Select Extremely unlikely Unlikely Likely Very Likely

2. If you had small pigmentation marks on the back of your hand or on your face, how keen would you be to remove them?

Please Select Very A Little Not bothered

3. How concerned are you about the following conditions as you age?

a. Age spots: Please Select Extremely concerned Somewhat concerned Not very concerned Not bothered

b. Rosacea: Please Select Extremely concerned Somewhat concerned Not very concerned Not bothered

c. Wrinkles: Please Select Extremely concerned Somewhat concerned Not very concerned Not bothered

d. Sagging: Please Select Extremely concerned Somewhat concerned Not very concerned Not bothered

e. Skin cancer: Please Select Extremely concerned Somewhat concerned Not very concerned Not bothered

4. Do you suffer from any of the skin conditions listed below?

Rosacea

Age/liver/sun spots

Acne

Scarring

Dry/flaky skin

5. Were you prone to blushing as a child? Please Select Yes No

6. Did you suffer from teenage acne? Please Select Yes No

7. Do you suffer from late onset acne? Please Select Yes No

8. Did your acne: Please Select persist into your late 20s or return in your 30's and 40's not applicable

9. If you have dry flaky skin - do you suffer from a dry scalp? Please Select Yes No

10. If you have eczema, would a cosmetic which reduces itching, reduces inflammation, improves skin condition and improves your skins ability to hold water without suffocating the skin be of value to you?

Please Select Yes No Not Applicable

11. If you suffer from blushing, did it become more pronounced and become flushing in your...

Please Select 20's 30's 40's 50's Not At All Not Applicable

12. Did your flushing become permanent reddening with acute flushing episodes in your...

Please Select 30's 40's 50's Not Applicable

13. Have you ever visited a doctor or specialist for treatment?

Please Select Yes No

14. If YES, what treatment was suggested - please list products where applicable.

15. If NO, which of the following, if any, do you feel would motivate you to talk to a doctor or specialist about your skin condition?

If you were to read an article in a magazine and/or take a quiz/survey about your condition

If you were to hear about a product designed to treat your skin condition

If you were to hear about a specific product from your doctor

If you were to hear about a specific product from your pharmacist

If you were to hear about a specific product from your friends/co-workers/relatives

If you were to receive an advertisement or a coupon for a specific product in the mail

Other
Please specify

16. Have you ever changed your daily activities to avoid situations that make these skin conditions worse?

Avoided the sun (UV)

Avoided alcohol, spicy foods

Limited outdoor activities

Changed the way you dress

Hidden your hands

Used camouflage make-up

Other
Please specify

17. Do you feel that your skin condition can ever be completely cured?

Please Select Yes No

18. Would you recommend any products that have cured/improved your skin condition?

Please Specify

Personal Details

Please provide the following personal information so a professionally trained advisor may call you to discuss which product(s) best suit your skin issue, based upon the answers you have supplied.

Alternatively, please call an advisor on 08701 909369 to discuss now.

*Name:


*Postcode:

*Telephone:


*E-mail:

Please enter a convenient day and time to call you on the above number.
Day Monday Tuesday Wednesday Thursday Friday Saturday (am only) Time 9am - 10.30am 10.30am - 12pm 12pm - 2pm 2pm - 3.30pm 3.30pm - 5pm 5pm - 7pm No Preference

How old are you?

Are you:
Please Select Male Female

How did you find us?:
Please Select: Dave ITV3 E4 Channel 4 MTV Viva Other TV Channel ____________________ Women And Home TEEN ZONE Twitter Facebook YouTube Repeat/Existing Customer SK:N Prof. Chu ____________________ Alta Vista Amazon Ask Jeeves Google Lycos MSN Wanadoo Yahoo ____________________ Daily Express Daily Mail Health Daily Mail Saturday Daily Mail Tuesday Daily Telegraph Guardian Times ____________________ Catalogue Ebay E-mail advert Blog Forum - Rosacea Forum - Yahoo Loyalty Account Recommended by friend Referred by clinic Referred by pharmacy Repeat customer Post mailing Samples Not sure Other

* Required