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1 Month Survey

Instructions: Please fill out the following questions as honestly and accurately as you can.

1 Month Survey

This form is only an example. It does not actually submit.

1.

What is your email address? (this is for verification purposes. Type in the same email address that we sent our email to).


2.

How old are you?

Under 18

18-25

26-39

Over 39


3.

Gender:

Male

Female


4.

Ethnicity:

African/African American

Asian

Hispanic/Latin American

Middle Eastern

Native American

Pacific Islander

White/European (non-hispanic)

Other


5.

Approximately how many days have you been taking Vilantae? (note: this email was sent 1 month after your first order, but that doesn't include the 2-3 days it took for delivery).


6.

On average, how many Vilantae capsules have you been taking per day?


7.

If you'd like to elaborate on your consistency you can do so here (optional).


8.

On a scale of 1 to 20, using these pictures as a guide, how bad was the acne on your face prior to taking Vilantae?

0 No Acne............................................................................................

1

2

3

4

5 Light Acne.......................................................................................

6

7

8

9

10 Moderate Acne............................................................................

11

12

13

14

15 Severe Acne..................................................................................

16

17

18

19

20 Extremely Severe Acne.................................................................


9.

What percentage of the acne on your face has been eliminated?


10.

On a scale of 1 to 20, using these pictures as a guide, how bad was the acne on your shoulders, back, and chest prior to taking Vilantae?

0 No Acne...................................................................................

1

2

3

4

5 Light Acne................................................................................

6

7

8

9

10 Moderate Acne.....................................................................

11

12

13

14

15 Severe Acne.........................................................................

16

17

18

19

20 Extremely Severe Acne........................................................


11.

What percentage of the acne on your shoulders, back, and chest has been eliminated?


12.

Is there anything besides Vilantae that could have been responsible for your reduction in acne? (optional).


13.

Have you noticed a reduction in the amount of oil on your skin?


14.

Have you had scarring from acne before?


15.

Did you experience any initial breakout when you started Vilantae?

no

yes, slightly

yes, moderately

yes, severely

not sure


16.

Have you noticed a loosening in your stool thickness?

no

slightly

moderately

occasional diarrhea

severe diarrhea


17.

Your thoughts or opinions about it? (optional).


18.

Did you experience skin flushing from taking Vilantae? ( a warming sensation on the skin).

no

yes


19.

Your thoughts or opinions about it (optional).


20.

Did you experience any stomach irritation from taking Vilantae?

no

yes, slightly

yes, moderately

yes, severely


21.

Your thoughts or opinions about it (optional).


22.

Are there any other side effects you'd like to report? (optional).


23.

If you asked your dermatologist or physician about Vilantae, how did they respond? (optional).


24.

Are there any other comments or suggestions that you'd like to make? (optional).


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