Facial Skin Survey - Breakouts and Blemishes Question Title * 1. First name (your personal information is never shared with anyone else) OK Question Title * 2. Last name OK Question Title * 3. Telephone number OK Question Title * 4. Email address OK Question Title * 5. What is your gender? Male Female OK Question Title * 6. What is your age? Under 18 18-24 25-34 35-44 45+ OK Question Title * 7. Which race/ethnicity best describes you? (Please choose only one.) American Indian or Alaskan Native Asian / Pacific Islander Black or African American Hispanic White / Caucasian Multiple ethnicity / Other (please specify) OK Question Title * 8. Do you experience acne blemishes or breakouts on your face? Yes No OK Question Title * 9. How often do you experience facial acne blemishes or breakouts? 1-3 days per month 3-7 days per month 7-14 days per month 14-21 days per month 21-31 days per month OK Question Title * 10. Do you take prescription medication (oral or topical) to help eliminate acne blemishes or breakouts? Yes No OK Question Title * 11. What do you currently use or do to help calm your acne blemishes or breakouts? (If none, please type none or N/A) OK Question Title * 12. What problems or concerns do you have about your facial skin? Extremely Concerned Very Concerned Somewhat Concerned Not Very Concerned Not at all Concerned Acne Blemishes Acne Blemishes Extremely Concerned Acne Blemishes Very Concerned Acne Blemishes Somewhat Concerned Acne Blemishes Not Very Concerned Acne Blemishes Not at all Concerned Dark Spots or freckles Dark Spots or freckles Extremely Concerned Dark Spots or freckles Very Concerned Dark Spots or freckles Somewhat Concerned Dark Spots or freckles Not Very Concerned Dark Spots or freckles Not at all Concerned Sensitive Sensitive Extremely Concerned Sensitive Very Concerned Sensitive Somewhat Concerned Sensitive Not Very Concerned Sensitive Not at all Concerned Uneven Skin Tone Uneven Skin Tone Extremely Concerned Uneven Skin Tone Very Concerned Uneven Skin Tone Somewhat Concerned Uneven Skin Tone Not Very Concerned Uneven Skin Tone Not at all Concerned Large Pores Large Pores Extremely Concerned Large Pores Very Concerned Large Pores Somewhat Concerned Large Pores Not Very Concerned Large Pores Not at all Concerned Fine Lines Fine Lines Extremely Concerned Fine Lines Very Concerned Fine Lines Somewhat Concerned Fine Lines Not Very Concerned Fine Lines Not at all Concerned Wrinkles Wrinkles Extremely Concerned Wrinkles Very Concerned Wrinkles Somewhat Concerned Wrinkles Not Very Concerned Wrinkles Not at all Concerned Redness Redness Extremely Concerned Redness Very Concerned Redness Somewhat Concerned Redness Not Very Concerned Redness Not at all Concerned Facial scars Facial scars Extremely Concerned Facial scars Very Concerned Facial scars Somewhat Concerned Facial scars Not Very Concerned Facial scars Not at all Concerned Other (please specify) OK Question Title * 13. Which photo above most closely resembles your acne blemishes or breakouts? 0 1 2 3 4 OK DONE
