Survey on the Physical Discomforts of Rosacea

Please fill out the following survey about your personal experience with physical discomforts of rosacea. Results will be reported in the National Rosacea Society's newsletter and on rosacea.org.

Question Title

* 1. Have you ever experienced physical discomfort associated with your rosacea?

All the time

Frequently

Occasionally

Never

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* 2. What type(s) of physical discomfort have you experienced? (Check all that apply.)

Burning

Stinging

Itching

Tightness

Tingling

Prickling

Swelling

Tenderness

Headache

Other (please specify)

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* 3. Where have you experienced discomfort? (Check all that apply.)

Cheeks

Nose

Chin

Forehead

Neck

Eyes

Ears

Behind ears

Scalp

Chest

Mouth

Other (please specify)

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* 4. Does your discomfort occur at the same time as the visible signs of rosacea?

Yes

Sometimes

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* 5. Has medical therapy improved your physical discomfort?

Yes

Somewhat

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* 6. Has medical therapy improved your visible signs of rosacea?

Yes

Somewhat

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* 7. Are you...

Male

Female

Non-binary/other

Prefer not to answer

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* 8. Are you...

Under 30

30-39

40-49

50-59

60-69

70 or older

Prefer not to answer

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* 9. Comment:

Question Title

* 10. Would you like to receive the latest information on rosacea? Join the NRS mailing list by providing your contact information below.

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address