1.
Gender
Male
Female
2.
Age
3.
Do you have a tendency to blush or flush easily with a persistent redness in the center of the face?
Frequently (daily)
Occasionally (weekly)
Rarely (about once a month)
Never
4.
Do you have small visible blood vessels, bumps and/or pus‐filled pimples?
Frequently (daily)
Occasionally (weekly)
Rarely (about once a month)
Never
5.
How often do you have dry, tight or itchy facial skin that may swell or thicken?
Frequently (daily)
Occasionally (weekly)
Rarely (about once a month)
Never
6.
Do you suffer from watery or irritated eyes or swollen eyelids?
Frequently (daily)
Occasionally (weekly)
Rarely (about once a month)
Never
7.
How long have you been experiencing any/all of these symptoms?
Less than a year
One to three years
Three to five years
More than five years