SkinStim Expanded Enrollment Questionnaire. Step 1 of 3 33% Name* First Last Email* Phone*CORE QUESTIONNAIREHow often do you use skin care products?NeverRarelySometimesOftenAlwaysHow often do you wear sunscreen?NeverRarelySometimesOftenAlwaysDo you use samples before purchasing a skincare product?NeverRarelySometimesOftenAlwaysHow often do you buy skin care products?NeverRarelySometimesOftenAlwaysHow often do you purchase facial treatments?NeverRarelySometimesOftenAlwaysDo you wear make-up regularly?NeverRarelySometimesOftenAlwaysHow likely would you be to try a new high-tech skin treatment?NeverRarelySometimesOftenAlwaysPlease check that you have ticked one box for each question before moving onto the next page. CONCERNS & INTERESTWhat skin problems or concerns would you like to address?What would you like to change about your skin?CURRENT HEALTH & LIFESTYLEHave you ever had any cosmetic procedures or laser treatments?If yes, please specify types of treatment and dates (e.g., chemical peel, laser, Botox, dermabrasion or microdermabrasion):Do you follow a home skin care regimen and how often? Yes No If Yes, check the items and identify the name of the products you use regularlySelect all that applyEye Makeup RemoverSoapCleanserToner/ AstringentDay CreamNight CreamScrub/ ExfoliantMaskEye CreamSerumSunscreenRetin-A® / Renova ®Retinol CreamAHA Product(s)Benzoyl PeroxideSkin Bleacher/ LightenerFoundationOther/ ListHave you had an allergic or irritant reaction to a skin care product(s)? Yes No Explain:Please tick below if you have experience any of the following skin conditions:BreakoutsCongested Skin (Blackheads, Milia)Dry Dehydrated SkinPigmentation (Dark Patches)Itchy, Dry SkinSensitive Skin (Redness, Dry, Sometimes Itchy)Fine Lines and WrinklesDull looking SkinOtherWhich of the following best describes your skin type? (Please select one type number) I Creamy complexion Always burns easily, never tans II Light Complexion Always burns, tans slightly III Light/Matte Complexion Burns moderately, tans gradually IV Matte Complexion Seldom burns, always tans well V Brown Complexion Rarely burns, deep tan VI Black Complexion Never burns, deeply pigmented GENERAL QUESTIONS:On average, how much do you spend on skincare products each month? Less than $20 $21-$40 $41-$60 $61-$80 $81-$100 More than $100 On average, how much do you spend on skincare treatments each month? Less than $100 $101-$200 $201-$300 $301-400 $401-$500 More than $500 Where do you find out about new facial treatments and products? Internet/online Pharmacy Specialized Beauty Shops Catalogues Department Stores Other
