Questionnaire about Rosacea

Please answer a few questions so that we can better understand your situation.**

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Your name:

Patient Name (if different)

Your Email Address:

  

Verify Email Address:

  

 Sex:   Female   Male
 Age:   

 Race:  

Weight:    (pounds)

How many years have you had rosacea?
  Less than 1 year
  1 to 5 years
  over 10 years

What symptom of Rosacea do you experience?

  Facial Flushing
  Pimples on the face
  Swollen Bumps on the nose
  Broken Capillary
  Eye Irritation

Where do your Rosacea symptom appear?

  Cheeks
  Nose
  Chin
  Forehead

Do you have any physical sensation of your Rosacea?

  None
  Pain
  Itchy
  Other

How Serious do you think your Rosacea is?

  Mild
  Moderate
  Severe

What type of treatment have you used before?

  Topical
  Oral

  Other

 Have you tried any alternative treatment?
  Yes  if Yes, what kind?
  No
 How did you hear about us?


Please Specify: (such as Google, WebMD, etc..)  

  

Please add any comments and questions you have below:

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**Even though we have herbal Doctors ready to answer your questions, we can not provide medical advise on-line. Your medical doctor who knows your clinical history is the only person qualified to give you medical advise. We can only guide your use of our product and let you know how our product may be able to benefit your personal case.