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Sensitive Skin Survey

FILL IN the following questionnaire completely.

1. DOES YOUR CHILD SHOW ANY SIGNS OF SENSITIVITY?

	Yes
	No

(if no, skip to question #3)

Since When?

	Birth
	Later on

if later on, specify around which age:

	1 to 6 months
	6 to 12 Months
	1 to three years
	3 to 6 years
	6+ Years

What are the signs?
Redness
Dryness
Stinging
Tightness
Burning Sensations
Pruritis (itching)

Specify any others:

How long do these signs last?

	A Few Minutes
	A Few Hours
	1 Day
	Several Days

2. WHICH TRIGGER FACTORS AFFECT YOUR CHILD?

Environmental factors

Yes	No
		Cold
		Heat
		Humidity
		Sun
		Sudden Changes in Temperature
		Smoking Environment
		Pollution

Physical factors

Does sensitivity seem to be related to:
pressure

	Perspiration/Physical Effort
	Contact with Synthetic Fabrics (Nylon, Polyester)
	Contact with Wool
	Scratching

Specify any others:

External factors

Does sensitivity seem to be linked to the use of: (select all options that apply)

Soap
Perfume
Cosmetics
Softener
Laundry Detergent
Hard Water
Shower
Bath
Swimming Pool

Emotional factors

When the skin shows signs of sensitivity, does your child seem: (select all options that apply)

More stressed than usual?
More upset than usual?
More irritable among others (school, day care)?
More irritable with the rest of the family?

Does skin sensitivity flare up more easily: (select all options that apply)

During intense emotions
During family problems

Specify any others: (select all options that apply)

3. CHILD

Sex:

	Male
	Female

AGE:

	1 to 6 months
	6 to 12 months
	1 to 3 years
	3 to 6 years
	6+ years

Demographics

4. FAMILY BACKGROUND

Is there a family background of sensitive skin?

(redness, stinging, tightness, burning sensations, pruritis, etc.)

	No
	Yes

(if no, skip to question #5)

Among siblings?

	No
	Yes

Among the parents?

Father
If yes, what are signs and symptoms?

Mother
If yes, what are signs and symptoms?

Is there a family background of allergies?
Among the parents? (select all options that apply)
Father
Mother

Yes	No	Type of Allergy:
		Eczema
		Asthma
		Allergic Rhinitis
		Hives
		Pruritis
		Food Intolerance
		other

Among the Siblings?

Yes	No	If yes specify number of allergic brothers and/or sisters

Allergic brothers and/or sisters:

Yes	No	Type of Allergy:
		Eczema
		Asthma
		Allergic Rhinitis
		Hives
		Pruritis
		Food Intolerance
		other

5. SKIN CARE

Has anyone made the diagnosis of "sensitive skin"? Please specify:

	Yes
	No

If yes, specify:

	Parents
	Pharmacist
	General Practitioner
	Pediatrician
	Dermatologist

Have any products already been used?

	Yes
	No

If yes, specify the following:

Based on recommendation or advice from the following: (select all options that apply)
Parents
Physician
Pharmacist
Brochure
Magazine
Internet Article

What other brands have you used on your child?

Specify any others:

Have you used Mustela Dermo-Pediatrics products?

	Yes
	No

If Yes, Specify:

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