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Exit Survey
 
 
1. How many times in the last 2 years have you been to a dermatologist?
 
1
 
2
 
3
 
4
 
5 or more times
 
 
 
2. What was the PRIMARY reason you visited the dermatologist? (on the last visit if more than one visit in the last year)
 
Acne
 
Rosacea
 
To evaluate a “suspicious” skin lesion
 
A skin rash
 
Eczema
 
Psoriasis
 
Annual skin cancer screening
 
Hair loss
 
Scar/skin pigmentation Treatment
 
Removal of skin tags
 
Education on the treatment of aging skin
 
Tumor removal
 
Cosmetic procedure ( for example dermabrasion, chemical peel, botox, liposuction)
 
Other
 
 
 
 
3. What part(s) of the body was affected by the condition listed in previous question? (check all that apply)
 
Scalp
 
Face
 
Neck
 
Arms (including hands and fingers)
 
Chest
 
Abdomen
 
Back
 
Legs
 
Feet

 
 
 
4. After treatment of the primary reason for your visit, did the dermatologist offer advice on maintaining good skin health?
 
Yes
 
No
 
If yes, list out advice.
 
 
 
 
5. Were you given a prescription?
 
Yes
 
No
 
If yes, for what?
 
 
 
 
6. Did the dermatologist give you a product to use that s/he compounded him or herself?
 
Yes
 
No
 
If yes, for what?
 
 
 
 
7. After treatment of the primary reason for your visit, did the dermatologist recommend OTC? (ie. available on the shelf at CVS or Walgreens - soaps, body washes, moisturizer, shampoo, lotion, deodorant, or other products to use)
 
Yes
 
No
 
If yes, list out type of product (ie soap and brand ie Lubriderm)
 
 
 
 
8. If the doctor recommended an OTC product: (choose all that apply)
 
The OTC was in addition to a prescription
 
The OTC was NOT in addition to a prescription
 
The OTC was instead of a prescription
 
The OTC was NOT instead of a prescription
 
Doctor recommended a single brand
 
Doctor recommended several brands
 
Doctor did not make a recommendation
 
If yes, why did the dermatologist want you to take this product? (use open field below)
 
If yes, did the dermatologist recommend a specific brand? (use open field below)
 
 

 
 
 
9. Which type of product have you asked your dermatologist for advice on? (check all that apply)
 
Soap
 
Body wash
 
Shampoo
 
Lotion
 
Deodorant
 
Moisturizer
 
I have never asked a dermatologist for advice on any of these skin care products
 
Other (please specify)