Republic of the Philippines

Mindanao State University

Maigo School of Arts and Trades
Maigo, Lanao Del Norte

Questionnaire
On
The Impact of Severe Acne Problem to students of
Mindanao State University – Maigo School of Arts and Trades

Part I : Respondents Profile

Name: ___________________________________ Gender: ( ) male ( ) female

Age: ( ) 11-14 ( ) 15-18 ( ) 19-22 ( ) 23 above
Skin Type: ( ) normal ( ) dry ( ) oily ( ) sensitive
Blood type: ( ) A ( ) B ( ) AB ( ) O
Economic Status: ( ) high ( ) middle ( ) low
Lifestyle:

DIRECTIONS: KINDLY PUT CHECK TO THE COLUMN THAT CORRESPONDS

TO YOUR DESIRED ANSWER ON THE FOLLOWING QUESTIONS.

5 – always 4 – often 3 – sometimes 2 – rarely 1 – never

A. SELF-ESTEEM 1 2 3 4 5
1. Does having severe acne affects your self-esteem?
2. Do you feel ashamed about your acne/face?
3. Do you feel conscious having severe acne?
4. Did you feel upset because of your acne?

B. PHYSICAL APPEARANCE
1. Have you been bullied because of having severe acne?
2. Do you wish to have clear skin?
3. Do you feel conscious about your acne?
4. Do you ever compared your physical appearance to the physical
appearance of others?
C. ACADEMIC PERFORMANCES
1. Do you think acne affects your academic performances?
2. Do you participate in any activities on class?
3.
4.

D. SOCIAL RELATIONSHIP
1. Is your acne affects you social status?
2. Are you confidence facing other people?
3. Does acne bothers you on facing/meet other people?
4.