Jevelle International
Skin Questionnaire
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Please fill out the questionnaire below. The more information you give us, the more we can help.
Or if you prefer you may email us directly with your questions.


General Information
Gender? Male Female
Age:
What country do you live in?
Other:
    Your Skin
    How long have you had acne? (years)
    Where do you breakout? (check all that apply) Face
    Chest
    Back
    Other:
    Is your skin:
    Mark all that apply to you: Blackheads
    Small Whiteheads
    Large Whiteheads
    Cysts
    Do you scar easily? Yes No
    How many days does it take for a pimple to go away?   days
    What is your hair color:
    What is your eye color:
    Complexion: Light Medium Dark
    Do you blush easily? Yes No
    Does your skin become dry easily? Yes No
    Do you wear a moisturizer daily? Yes No
    If so, where?
    Your Lifestyle
    How much time do you spend in the sun each day? Summer: hours
    Winter: hours
    If you smoke, how many cigarettes each day?
    How many hours do you sleep each night?
    How many glasses do you drink each day of: Water
    Caffeinated Drinks
    Alcoholic Drinks
    Are you a student? Yes No
    Your Acne Treatment History
    Are you sensitive to any of these products:
    Retin-A
    Salicylic Acid
    Glycolic Acid/AHA's
    Benzoyl Peroxide
    Sunscreen
    What have you tried for your acne?
    For women only
    Do you wear makeup? Yes No
    Do you menstruate? Yes No
    How frequently (i.e. monthly, every 6 weeks, ...)
    Are you pregnant ? Yes No
    Breast-feeding? Yes No
    Do you take birth control pills? Yes No
    Brand:
    For men only
    Does shaving cause you to breakout?  Yes No
    How often do you shave? Daily 3x/week Less than 3x/week
    What type of shaver do you use? electric shaver hand-held razor
    Shaving creme Yes No
    Tell us about yourself
    If there is anything else that we should know about you?
    Required Information
    E-mail address
    Optional Information
     
    Name
    Address
    Phone number
    (include area code)
    How did you hear about us?
    URL or Publication Name:
    Submit Questionnaire



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Jevelle International P.O. Box 5058 Gardena, CA USA
Email: barbara@jevelle.com     Tel: (877) 538-3553
All page contents 1999 Jevelle International Inc.