|
#1 |
1 |
|
|
 |
Welcome
Q: How old are you ?
12-17 #2 (+2) 18-40 #2 (+1) Above 40 #2 (+3)
Variables: grade
|
|
#2 |
3 |
|
|
|
(no title)
Q: For how long have you had acne?
Less than 6 months #3 6 months - 2 years #3 More than 2 years #3
|
|
#3 |
3 |
|
|
|
Have you tried any treatment for a significant (at least a month or more) period of time? (Multiple Choice can be selected)
Continue #4
Data Entry Fields: H, H, H, H, H, H
|
|
#4 |
1 |
|
|
|
(no title)
Q: Do you have sensitive skin?
Yes #5 (+3) No #5 (+1) I Don't Know #5 (+2)
3
Variables: skin
|
|
#5 |
3 |
|
|
|
(no title)
Q: What is your skin type?
Dry #6 (+1) Regular #6 Oily #6 (+3) Combination (T-Zone) #6 (+2) I'm Not Sure #6 (+1)
Variables: skin
|
|
#6 |
5 |
|
|
|
(no title)
Q: How many times do you wash your face per day with soap/facewash?
1-2 times #7 (+1) 3-5 times #7 (+2) More than 5 times #7 (+2)
Variables: habits
|
|
#7 |
3 |
|
|
|
(no title)
Q: Do you have dandruff?
Yes #8 (+3) No #8 (+1) I'm not sure #8 (+2)
Variables: skin
|
|
#8 |
3 |
|
|
|
Describe your acne
Only Blackheads #38 Mild #9 (+1) Moderate #9 (+3) Severe #9 (+5)
Variables: acne
|
|
#9 |
3 |
|
|
|
Which of the following best describes your acne?
Continue #10
Data Entry Fields: Acne_1, Acne_2, Acne_3, Acne_4, Acne_5
Variables: acne, acne, acne, acne, acne
|
|
#10 |
1 |
|
|
|
(no title)
Q: Do you experience pain?
Yes #11 (+2) No #11 (+1)
Variables: acne
|
|
#11 |
2 |
|
|
|
(no title)
Q: Where is your face most affected by acne?
Concentrated in some areas #12 (+5) More than Half #13 (+3) Less than half #13 (+2) Scattered #13 (+1)
Variables: acne
|
|
#12 |
1 |
|
|
|
Select all that apply (Multiple choice can be selected)
Continue #13
Data Entry Fields: Face_1, Face_2, Face_3, Face_4, Face_5, Face_6
Variables: acne, acne, acne, acne, acne, acne
|
|
#13 |
4 |
|
|
|
(no title)
Q: What would be the approximate no. of acne on your face?
0-5 #49 (+1) 5-10 #49 (+2) 10-20 #49 (+3) 20-30 #49 (+4) More than 30 #49 (+5)
Variables: acne
|
|
#16 |
2 |
|
|
|
(no title)
Q: Does your acne leave behind
Pigmentation #17 (+2) Scars #17 (+3) No marks #17 (+1)
Variables: acne
|
|
#17 |
3 |
|
|
|
(no title)
Q: Does anyone else in your immediate family have acne ?
Yes #18 (+2) No #18 (+1)
Variables: cause
|
|
#18 |
2 |
|
|
|
(no title)
Q: Do you notice acne breakouts prior to periods?
Yes #19 (+3) No #19 (+1) I'm not sure #19 (+2)
Variables: cause
|
|
#19 |
3 |
|
|
|
(no title)
Q: How are your periods?
Mostly Regular #20 (+1) Mostly Irregular #20 (+3)
Variables: cause
|
|
#20 |
2 |
|
|
|
PolyCystic Ovary Syndrome (PCOS) is a condition that affects women's hormonal levels.
Q: Have you been diagnosed with PCOS?
Yes #26 (+3) No #26 (+1) I'm not sure #26 (+2)
Variables: cause
|
|
#21 |
1 |
|
|
|
(no title)
Q: Now tell us a little about your nutrition and habits ! This helps us in suggesting better treatment methods :)
Continue #27
|
|
#22 |
1 |
|
|
|
(no title)
Q: Now tell us a little about your nutrition and habits ! This helps us in suggesting better treatment methods :)
Continue #27
|
|
#23 |
1 |
|
|
|
(no title)
Q: Now tell us a little about your nutrition and habits ! This helps us in suggesting better treatment methods :)
Continue #27
|
|
#24 |
1 |
|
|
|
(no title)
Q: Now tell us a little about your nutrition and habits ! This helps us in suggesting better treatment methods :)
Continue #27
|
|
#25 |
1 |
|
|
|
(no title)
Q: Now tell us a little about your nutrition and habits ! This helps us in suggesting better treatment methods :)
Continue #27
|
|
#26 |
3 |
|
|
 |
Logic:
acne ≤ 14 #21 acne ≤ 24 #22 acne ≤ 34 #23 acne ≤ 44 #24 acne ≥ 45 #25 default #1
Variables: acne
|
|
#27 |
5 |
|
|
|
(no title)
Q: How much of plain water do you drink per day?
2-4 glasses #28 (+2) 4-8 glasses #28 (+1) More than 8 glasses #28 (+1)
Variables: food
|
|
#28 |
3 |
|
|
|
(no title)
Q: How often do you consume dairy products?
Never #29 2-3 times a week #29 (+1) More than 3 times a week #29 (+1) Once a day #29 (+3) Twice a day or more #29 (+3)
Variables: food
|
|
#29 |
5 |
|
|
|
(no title)
Q: How often do you consume oily/fried/fast/sugary foods at home or out?
Everyday #30 (+3) 3-4 times a week #30 (+2) 1-2 times a week #30 (+1) Never #30
Variables: food
|
|
#30 |
4 |
|
|
|
(no title)
Q: How is your bowel movement?
Mostly Constipated #31 (+3) Mostly Regular #31 (+1)
Variables: food
|
|
#31 |
2 |
|
|
|
(no title)
Q: What is the frequency of passing the stool?
Everyday #33 (+1) Once in 2 days #33 (+2) Once in more than 2 days #33 (+3)
Variables: food
|
|
#33 |
3 |
|
|
|
Do you regularly experience any of the following symptoms?
Continue #39
Data Entry Fields: Sym, Sym1, Sym2, Sym3, Sym5
Variables: food, food, food, food
|
|
#38 |
1 |
|
|
|
(no title)
|
|
#39 |
1 |
|
|
|
(no title)
Q: Do you regularly smoke or use tobacco products?
Yes #40 (+3) No #40 (+1)
Variables: habits
|
|
#40 |
2 |
|
|
|
(no title)
Q: Do you regularly consume alcohol?
Yes #41 (+3) No #41 (+1)
Variables: habits
|
|
#41 |
2 |
|
|
|
(no title)
Q: Over the last 12 weeks (at most times) what has been your state of mind?
Generally Happy #42 (+1) Mood Swings #42 (+3) Stressed #42 (+3) Depressed #42 (+3) Anxious #42 (+3)
Variables: mood
|
|
#42 |
5 |
|
|
|
(no title)
Q: Any known allergies or sensitivities?
Yes #43 (+3) No #43 (+1) I'm not sure #43 (+2)
Variables: cause
|
|
#43 |
3 |
|
|
|
(no title)
Declaration #47
|
|
#47 |
1 |
|
|
|
(no title)
|
|
#49 |
5 |
|
|
|
(no title)
Q: Do you have acne on other parts of your body ?
Yes #50 No #16
|
|
#50 |
1 |
|
|
|
Select all that apply (Multiple choice can be selected)
Continue #16
Data Entry Fields: Body_1, Body_2, Body_3, Back_4
Variables: acne, acne, acne, acne
|
|
Select All |
