Thank you for participating in this anonymous survey
All responses will be kept completely confidential. We will use answers received toward providing researchers with information that may aid in eventually curing Melasma. Please keep your answers simple!
1.
How old are you?
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
over 80
2.
Have you ever been on oral contraceptives and/or hormonal replacement therapy? Yes
No
If yes, how long and what were you prescribed?
3.
Have you ever suffered from a severe sunburn on your face? Yes
No
If so, please explain.
4.
Have you ever used indoor tanning booths? Yes
No
If so, how often?
5.
Please explain your past sun exposure.
6.
When did you first notice your melasma/hyperpigmentation condition?
7.
How long have you had melasma?
8.
Please list all treatments both topical or otherwise that you have already tried to help reduce your pigmentation problem. List treatment and the result.
9.
Please describe your skin type:
Fair
Medium
Medium/Dark
Dark
Ethnic
10.
What ethnicity are you?
11.
Have you ever been on a low carb diet such as the atkins diet? Yes
No
If so, how long?
12.
Since you have had melasma, has the texture of your hair changed to a more course/wiry texture?
Yes
No
13.
Do you currently use a make-up to cover your condition? Yes
No
If so, what brand?
14.
Would you be willing to share your before and after photos on our website? Yes
No
15.
As a melasma sufferer, please explain what is the most frustrating thing about your condition and how we could help.
16.
On a scale of 1-10, 1 being mild and 10 the most severe, how would you rate your condition?
1
2
3
4
5
6
7
8
9
10
17.
Did your Melasma start during a very stressful time in your life? If so, please explain.