Houston Studies - Skin Conditions September 2017

1. Introduction Section

Plaza Research Houston is conducting a study on Skin Conditions that has several phases. Please complete the phase 1 survey. If you meet the requirements, we will follow up with you with a more in-depth questionnaire and details. There is a possibility of up to $325 for completing all phases, which includes picking up a product at our office and using for a preset amount of time, and completing several questionnaires.

Please answer the questions below. If you look like a match, we will contact you by telephone.

**Due to the large response to our surveys, we are only able to contact those that look like a match. Please continue to answer future studies, as you may be a match to those.

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* 1. Please provide us with the following information. We will be contacting you by telephone if you seem like a match.

Name:

ZIP/Postal Code:

Email Address:

Phone Number:

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* 2. Alternate Contact number

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* 3. What is your age? Whole number, no ranges or words

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* 4. What is your gender?

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* 5. Have you been diagnose by a doctor with any of the following?

Rheumatoid Arthritis

Eczema

Hives

Shingles

Dermatitis

Psoriasis

None of the above

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* 6. How often, if at all, do you typically use a lotion, cream or ointment for your....

	2+ times a day	1 time / day	5-6 times per week	3-4 times per week	1-2 times per week	I do not have
Rheumatoid Arthritis	Rheumatoid Arthritis 2+ times a day	Rheumatoid Arthritis 1 time / day	Rheumatoid Arthritis 5-6 times per week	Rheumatoid Arthritis 3-4 times per week	Rheumatoid Arthritis 1-2 times per week	Rheumatoid Arthritis I do not have
Eczema	Eczema 2+ times a day	Eczema 1 time / day	Eczema 5-6 times per week	Eczema 3-4 times per week	Eczema 1-2 times per week	Eczema I do not have
Hives	Hives 2+ times a day	Hives 1 time / day	Hives 5-6 times per week	Hives 3-4 times per week	Hives 1-2 times per week	Hives I do not have
Shingles	Shingles 2+ times a day	Shingles 1 time / day	Shingles 5-6 times per week	Shingles 3-4 times per week	Shingles 1-2 times per week	Shingles I do not have
Dermatitis	Dermatitis 2+ times a day	Dermatitis 1 time / day	Dermatitis 5-6 times per week	Dermatitis 3-4 times per week	Dermatitis 1-2 times per week	Dermatitis I do not have
Psoriasis	Psoriasis 2+ times a day	Psoriasis 1 time / day	Psoriasis 5-6 times per week	Psoriasis 3-4 times per week	Psoriasis 1-2 times per week	Psoriasis I do not have

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* 7. Which statement(s) describe your knowledge of eczema / atopic dermatitis?

I’ve been diagnosed by a medical professional (dermatologist, doctor, etc.)

I am self-diagnosed

A friend, relative, or acquaintance told me I have the condition

I’m not sure but I think I have eczema / atopic dermatitis

None of the above

Other (please specify)