Sample questionnaire for damaged skin assembled all the reasons behind damaged skin and what makes the skin damaged by surveying damaged skin sufferers and experts for remedies in order to help common people and skin product manufactures.

Fill your details:

Name: ________________
Gender: _______________
How old are you:  ________________
Area/ district you live: ______________

Damaged Skin Questionnaire Sample:


Do you have damaged skin?
Yes b) no

Which part of your skin is damaged?
Specify your answer: _______________

Do you have fine lines on your skin?
Yes b) no c) sometimes

What is the damage percentage of your skin?
Specify your answer: ______________

What damage issue you have?
Patchy skin
Pigmentation
Acne
Broken skin
Lifeless/ dull skin
Tan skin
Any other___________

How many hours a day you work out? Or expose your skin to sun?
Specify your answer: ______________

Do you have unwanted / more hair on your skin?
Yes b) no c) sometimes

What is the type of your skin?
Oily b) dry c) normal d) any other ____________

Are you applying any lotion on your damaged skin to protect your skin from more damage?
Yes b) no c) sometimes

What type of damaged skin you have?
Seasonal b) all time c) any  other _________

From how many days you are suffering from this type of damage?
Specify your answer: ___________

How many times a day you prefer to clean your skin?
Specify your answer: __________

How often you get skin allergies?
Specify your answer: ______________

Do you have itching sensation on your damaged skin?
Yes b) no c) sometimes

What is the color of your skin?
Dark b) light c) normal

Which type of damage you have?
Dark skin
Sun burned
Actinic keratosis
Any other

Are you taking your diet properly in time?
Yes b) no c) sometimes

Which vitamin you are consuming more?
Specify your answer:___________

Which SPF sun screen protection factor you are using?
15 b) 30 c) 45 d) 60 e) above 60 d) not using

Did you get this damaged skin from any skin products?
Yes b) no c) sometimes

Do you have hypertension?
Yes b) no

What all medicines you are using?
Mention all ________________

Did you consult doctor for this damaged skin issue?
Yes b) no