Oral Care Survey Question Title * 1. Contact Information First and Last Name City State Primary Phone Number Secondary Phone Number Question Title * 2. What is your gender? Female Male Question Title * 3. How old are you? Under 18 18-21 22-30 31-34 35-39 40-44 45-49 50-54 55-65 66+ Question Title * 4. What is the last level of education? Less than High School High School Grad Some College Completed College Some Post Grad. or more Question Title * 5. On a scale of 1-10, what is your level of comfort utilizing apps and blogs on the internet? 1 5 10 Clear i We adjusted the number you entered based on the slider’s scale. Question Title * 6. Thinking of the past twelve months, which of the following types of products, if any, have you, yourself, purchased? Air freshener/air care product Fabric care products Hair/Beauty care products Health care products Home cleaning products Oral care products Paper products Pet care products None of the above Question Title * 7. Who in your household is the primary decision maker for groceries and oral care products, such as toothpaste and mouthwash, purchased for use in your home? Yourself Spouse Shared equally between yourself & spouse Other (please specify) Question Title * 8. How often, if ever, do you, yourself, typically use each of the following oral care products? Toothpaste Manual Toothbrush Battery Operated Toothbrush Electric Toothbrush (Any brush that plugs into a power source) Mouthwash/Mouth Rinse Dental Floss/Tape Whitening Product (other than toothpaste) Other (please specify) Question Title * 9. What one brand of mouthwash / mouth rinse are you currently using? ACT (any) AIM ARM & HAMMER BIOTENE CEPACOL COLGATE ENAMEL HEALTH COLGATE OPTIC WHITE COLGATE TOTAL SMART MOUTH LISTERINE ADVANCED LISTERINE WHITENING SONICARE BREATH RX SCOPE THERABREATH REACH COMPLETE CARE TOMS OF MAINE Prescription mouthwash / mouth rinse (Any) Store Brand Do not use mouthwash / mouth rinse Other (please specify) Question Title * 10. Which of the following products or ingredients, if any, are you allergic or sensitive to? Ingredients in mouthwash / mouth rinse products Scents or perfumes in body lotions Ingredients in antiperspirants Cinnamon flavored products Alcohol in oral care products Hydrogen peroxide Cetylpyridinium Chloride None of the above Done
