Register Now:
	Your First Name:   Your Last Name:         Your Email:   Re-enter Your email:     Phone:       (i.e. 408)   (i.e. 383-3455) Cell Phone :       (i.e. 408)   (i.e. 383-3455) If you have a Study Code, Enter it here: (If you do not have a study code, enter "None")   Where did you hear about this study?   (i.e. Craig's List, News Paper, Mail, Online, Friend, Flyer, or Our Center)
	Age Range:
	12 to 15 16 to 17 18 to 20 21 to 24
	25 to 28 29 to 33 33 to 36 36 to 38
	38 to 41 42 to 45 45 to 48 49 to 54
	55 to 58 59 to 64 65 to 68 69 to 75
	76 and Over
	Sex:
	Female Male
	Race:
	American Indian Asian Black
	Hispanic/Litino White
	Days you are available to spend 1-2 hours in a product focus group: Check all boxes/days which apply
	Mon: Tue: Wed: Thu:   Fri: Sat: Sun:
	Best times of the Day for me are:
	8-9 AM 9-11 AM 11AM-1 PM 1- 2 PM
	2-4 PM 4-6 PM 6-8 PM 8-10 PM
	Face Skin Type Assessment Questionnaire
	1. How do you describe your skin type
	Sensitive
	Combination
	Dry
	Oily
	Dry in some areas and smooth in others.
	2. How do you describe your skin condition: (choose one or more)
	Sensitive
	Dehydrated
	Irritated
	Acne
	Aging and/or Age Spots or freckles
	3. How do you describe your skin condition: (choose one or more)
	Tight, as though it's too small for your face.
	Smooth and comfortable.
	Dry and itchy in places.
	Fine - quite comfortable.
	Dry in some areas and smooth in others.
	4. If you use a cream cleanser, how does your skin feel?
	Relatively comfortable.
	Smooth and comfortable.
	Sometimes comfortable, sometimes itchy.
	Quite oily.
	Oily in some areas and smooth in others. What is the cream cleanser product you are using now:
	5. By the middle of the day, how does your skin usually look?
	Flaky patches appearing.
	Fresh and clean.
	Flaky patches and some redness.
	Shiny.
	Shiny in the T-zone.
	6. Does your skin break out at all, if so how often?
	Hardly ever.
	Occasionally, perhaps before or during your period (for women).
	Occasionally.
	Often.
	Often - in the T-zone.
	7. If you use a facial toner, how does your skin react?
	It stings.
	No problems.
	Stings and itches.
	Feels fresher.
	Feels fresher in some areas but stings in others. What is the toner product you are using now
	8. If you use a rich night cream, how does your skin react?
	It feels very comfortable.
	Comfortable.
	Sometimes feels comfortable, other times feels irritated.
	Oily in the T-zone, and comfortable on the cheeks. What is the night cream product you are using now:
	HAIR CARE QUESTIONS:(SKIP THIS SECTION)
	1. How do you describe your scalp type
	Sensitive
	Itchy or Flaky
	Dry
	Oily
	Damaged
	2. Do you color your hair?
	Yes
	No
	3. How often do you color your hair?   Approximately every 30 to 45 days   Approximately every 60 days   Approximately every 90+ days   N/A I do not color my hair   4. If you color your hair, is it done by?   Yourself or by a friend   At a salon   N/A I do not color my hair   5. Describe your hair Length?   Short above the shirt collar   Medium Length – (shoulder length)   Long below shoulders   Long – mid back   Very Long – waist length   6. How often to you shampoo your hair?   Daily   2 - 3 times a week   1 - 2 times a week   7. How often to you condition your hair?   Daily   2 - 3 times a week   1 - 2 times a week   8. Where do you purchase your hair care products?   My Salon?   A Retail Store   Online   I do not know, someone else buys the product   BODY CARE PRODUCT QUESTIONS:(SKIP QUESTIONS 1-6)   1. How do you describe your skin type   Sensitive   Itchy or Flaky   Dry   Oily   2. Do you use a body scrub in the shower or bath?   Yes   No   None   3. How often do you take a relaxing bath?   Daily   2 - 3 times a week   1 - 2 times a week   4. Approximately how many skin care/bath products do you use for your bath?   1 - 2   2 - 4   4+   5. Do you use an “after-bath product i.e. a skin moisturizer or body oil”?   Yes   No   6. Where do you purchase your skin-bath products?   From my Salon or Spa   From a neighborhood retail store i.e. Safeway, Albertsons, Walgreens etc.   From a department store: i.e. Niemen’s, Macys, Nordstrom   Online Store   I do not know, someone else buys the product or I get them as gifts   7. Have you sometimes have allergies: (Please choose one or more that may apply) Yes No   Allergic Dermatitis Allergic Rhinitis Angioedema Anaphylaxis Aspirin Sensitivity Asthma Atopic Dermatitis Bird Allergy Canary Allergy Candida Cat Allergy Chemical Sensitivity Chicken Allergy Conjunctivitis Chronic Fatigue Contact Dermatitis Cosmetic Allergy Cows Milk Allergy Dermatitis Dog Allergy Drug Reaction Duck Allergy Dust Allergy Dust Mite Allergy Eczema Goose Allergy Grass Allergy Hayfever Headaches Heart Irregularity Hives Hypoglycaemia Milk Allergy Inhalent and Epidermal Allergens Lactose intolerance Migraine Headaches Mite Allergy Nettle Rash Parrot Allergy Parakeet allergy Perennial Rhinitis Pidgeon Allergy Pollen Allergy Rhinitis Rhus Tree Allergy Salicylate Sensitivity Sinusitis Skin Rash Sparrow Allergy Turkey Allergy Urticaria Yeast Allergy
	Diet Preferences:
	How do you describe your eating Preferences?
	Vegan
	Vegetarian
	Modified Vegetarian (some meats)
	Meat Included in basic diet
	Do you shop specifically for Organic Products?
	Yes
	No
	Doesn’t matter
	Do you shop specifically for Natural Products?
	Yes
	No
	Doesn’t Matter
	If you knew the product was Organic would you be willing to pay more?
	Yes
	No
	Doesn’t Matter