Age:
Select One
13-17
18-24
25-29
30-34
35-39
40-44
45-50
51+
Sex:
Female
Male
Marital
Status:
Select One
Single
Married
Separated
Divorced
Widowed
Do
you have children?
Yes
No
Education:
Select One
Some high school
High school graduate
Some college
College graduate
Beyond college graduate
Household
income:
Select One
Under $20,000
$20,000 - $39,000
$40,000 - $59,000
$60,000 - $74,000
$75,000 - $99,000
$100,000 - $149,000
$150,000 and up
Occupation:
Select One
Professional/Managerial
Clerical/Service
Sales
Homemaker
Student
Retired
Not Employed
Other
1)
How did you learn about this site?
iVillage
Link from another site
Advertisement
Ad banner
News or magazine article
Recommendation
Other
Search engine
Select One
Yahoo
Excite
Lycos
Netscape
go.com
Altavista
Other
2)
How many times have you visited this site in the past
3 months?
First visit
2-4 times
More than 4
3)
Do you currently have a dermatologist? (If Yes, skip
to question 6)
Yes
No
4)
If not, have you ever seen one?
Yes
No
5)
Do you plan to visit a dermatologist in the near future?
Yes
No
Not sure
6)
Do you currently use RENOVA® (tretinoin cream)?
Yes
No
Used Previously, but not using now
6a)
If Yes, when did you start using RENOVA?
Month
Select One
Jan
Feb
Mar
Apr
May
Jun
July
Aug
Sep
Oct
Nov
Dec
Year
Select One
1996
1997
1998
1999
2000
2001
6b)
If yes, what RENOVA formulation do you currently use?
RENOVA 0.02% Cream (green tube)
RENOVA 0.05% Cream (white tube)
7)
What type of doctor recommended RENOVA for you?
Select One
Dermatologist
Plastic Surgeon
Family Physician
General Practitioner
OB/GYN
Other
8)
If you are using or did use RENOVA, what is/was your
level of satisfaction with the product?
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
9)
Have you registered for a free Skin Therapy Brochure
and $5 Gift Certificate for RENOVA? (If No, skip to
question # 11.)
Yes
No
10)
If you answered "Yes" to question # 9...Have
you redeemed your $5 Gift Certificate?
Yes
No
Never received it (If not, please accept our apologies
and fill out the registration form after you click 'submit'.
We will send you a new one ASAP.)
11)
Which, if any, of the following anti-aging skin care
products do you use? (check all that apply)
12)
Overall, how do you rate your level of satisfaction
with these products?
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
13)
Are you currently using the following on a daily basis?
Moisturizer with sunscreen
Moisturizer only
Sunscreen only
None of the above
14)
Would you be interested in attending an online chat
on skin care at this site?
Yes
No
15)
If you would like for Ortho Dermatological to contact
you by e-mail regarding special events, new information
or product offers, please enter your full e-mail address
here:
Thank
you -- you're done! Please do not forget to click the
submit button.