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Web Site Questionnaire

Free cleansing product (worth at least £9.99) with all
correctly completed questionnaires*

Fill in the form below so a professionally trained advisor may evaluate your answers and call you to give advice and arrange delivery of your product.

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

*Delivery charges will apply

Skin condition

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?

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?

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

a. Age spots:

b. Rosacea:

c. Wrinkles:

d. Sagging:

e. Skin cancer:

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?

6. Did you suffer from teenage acne?

7. Do you suffer from late onset acne?

8. Did your acne:

9. If you have dry flaky skin - do you suffer from a dry scalp?

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?

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

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

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

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

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

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

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

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:


* Email:

Please enter a convenient day and time to call you on the above number.

How old are you?

Are you:

How did you find us?:

* Required

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