Questionnaire about Rosacea

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

If you like to send us your picture, please send it with your name to doc@merryclinic.com

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 is your Skin Type? 
Oily   Normal   Dry   Sensitive   Combination

What type of treatment have you used before?
Topical  Oral Other

Have you tried any alternative treatment?
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.