Jevelle International
Questionnaire

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 heal?	days
Hair color:
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:

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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.

Jevelle International Questionnaire

Jevelle International
Questionnaire