Lawrence Cutsinger's Hair Care Survey Please Enter Your First Name (or alias): Please Enter Your City: Please Enter Your State or Province: Your Sex: Male Female No Reply Select Your Age Range: --- Please Choose ------------------------- 17 to 19 Years 20 to 22 Years 23 to 25 Years 26 to 30 Years 31 to 35 Years 36 to 40 Years 41 and Above At what AGE did you notice hair loss? --- Please Choose ------------------------- 14 to 16 Years 17 to 19 Years 20 to 22 Years 23 to 25 Years 26 to 30 Years 31 to 35 Years 36 And Above Was your first NOTICEABLE hair loss where you usually FIRST apply shampoo to your head? Yes No No Reply What is the LOCATION of your first noticeable baldness? --- Please Choose ------------------------- Left Side Right Side Crown Back Are You Left Handed Or Right Handed? Right Left No Reply What type of hair do you have? Do you have gray hair? --- Please Choose ------------------------- No Graying Some Graying Moderate Graying A Lot Of Graying Men: Is your haircut: --- Please Choose ------------------------- Short Hair Skinhead Neither Men and Women: Please Answer Yes Or No To the Following Do you have curly hair? Yes No No Reply Do you have very oily hair? Yes No No Reply Do you have "thick" hair? Yes No No Reply Do you have LARGE diameter hair? Yes No No Reply About Your Hair Care Does your shampoo contain Sodium (or Ammonium) Laurel Sulfate (or Laureth Sulfate)? Yes No No Reply How often do you wash your hair? --- Please Choose ------------------------- Twice A Day Once A Day Every Other Day Every Two Days Every Three Days Every Four Days Every Five Days Every Six Days Once A Week How long do you wash your hair? --- Please Choose ------------------------- 1-2 Minutes 2-4 Minutes 4-6 Minutes 6-8 Minutes 8-10 Minutes Longer Do you diligently rub into scalp: Yes No No Reply Do you "repeat"? Yes No No Reply Do you rinse immediately or wait a while? Rinse Immediately Wait No Reply If you use hair conditioner, gel, or hairspray, what is the approximate COMBINED TOTAL of times per week that you use those products? --- Please Choose ------------------------- Five or more times per week Ten or more times per week Fifteen or more times per week Additional Information Are you a visitor who is balding (or know someone who is) but need MORE persuasion even after having read getitback.com? Yes No No Reply Are you a spectator (which would include media, government, soap and cosmetic industries)? Yes No No Reply Are you willing to show before and after photos of your test results? Yes No Maybe No Reply Are you considering conducting a formal test (Student Groups / Professors)? Yes No Maybe No Reply Comments? Please be brief. (254 character Limit)