Comprehensive Survey Form Step 1 of 2 50% ABOUT YOURSELFName* First Last Email* Date of Birth* MM slash DD slash YYYY Gender* Female Male Please describe your race/ethnicity.* Where do you currently reside (if you travel a lot, where do you spend the most time)?* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What is your occupation? What oral and topical medications do you currently take by mouth and/or apply to your skin (including the scalp)? (Write 'none' in the space provided if you do not take any medications)OralTopicalNoneAre you currently pregnant?* Yes No Have you had a child in the past year?* Yes No Have you been seen by a dermatologist within the past year?* Yes No Have you been diagnosed with a particular skin or scalp condition?* Yes No Are you happy with your dermatologist?* Yes No Have you been to a hair stylist within the past year?* Yes No How often do you go?* More than once a week Once a week Every two weeks Every three weeks Once a month Between once a month and every two months Every three months (4 times a year) 3 times a year 2 times a year 1 time a year What hair services do you have when you go? (Check all that apply)* Wash/shampoo Hair cut/trim Partial shave/buzz Blow dry Hooded dryer Roller set Cornrolls Twists (along the scalp) Double-stranded twists Weave/Extensions Wrap Stretching Styling using heat appliances such as a flat iron, curling iron, Marcel irons and/or Hot/pressing combs Hair treatments (Color, Keratin, Relaxer, Texturizer, Curly Perm, etc.) Other Please specify Other?* Are you happy with your current stylist?* Yes No Do you use hair accessories (rubber bands, clips, barrettes, hair/Bobby pins, hair bands, etc.)* Yes No Please list the hair accessories that you use (ex: rubber bands, clips, hair/Bobby pins, hair bands, etc.)*What is your PRIMARY hair style (the way that you wear your hair most of the time)? (Please choose only one answer.)* Pulled back into pony-tails, buns, or rolls Loose without much tension or pulling Braids or twists along the scalp such as cornrolls Loose with some braids or twists along the scalp such as cornrolls Individual braids or twists Extensions, weaves, or wigs that require the use of purchased hair to add to your existing hair Bantu knots Partial shave/buzz What is your SECONDARY hair style (the second most frequently worn style)? (Please choose only one answer.)* Pulled back into pony-tails, buns, or rolls Loose without much tension or pulling Braids or twists along the scalp such as cornrolls Loose with some braids or twists along the scalp such as cornrolls Individual braids or twists Extensions, weaves, or wigs that require the use of purchased hair to add to your existing hair Bantu knots Partial shave/buzz I do not have a secondary hair style What is your SHORTEST hair length? (Please measure the extended length of the SHORTEST section of your hair.) Note: Do not include breakage that usually occurs around the edges (the perimeter) of your hair.* SHORTEST hair length (inches)What is your LONGEST hair length? (Please measure the extended length of the LONGEST section of your hair.) Note: Do not include breakage that usually occurs around the edges (the perimeter) of your hair.* LONGEST hair length (inches)Which option below describes your natural hair color? (Please choose only one answer.)* Black Dark Brown Brown Light Brown Blonde Red/Orange Please indicate your level of satisfaction with your hair.* Very happy Happy Neutral (neither happy nor unhappy) Unhappy Very unhappy Which of the following, if any, do you experience as a problem or a concern with your hair? (Select all that apply)* Breakage Hair color/dye fading Dandruff/flaking Dry scalp Dullness Dry/straw-like Fly-aways Fragile/brittle Graying Grows too slow Itchy scalp No body/volume Oily scalp Split ends Thinning/losing hair Too coarse Too curly Too fine/thin Too frizzy Too oily Too straight Doesn't stay straight Doesn't stay curly Environmental humidity Unruly Other (Be very specific. Can be based on your hair quality, hair density, hair diameter, hair length, how the hair behaves or how it looks.) Please specify Other?* (Be very specific. Can be based on your hair quality, hair density, hair diameter, hair length, how the hair behaves or how it looks.)Which of the following describes(s) your approach to solving your hair problems? (Select all that apply)?* Seek advice/treatment from a dermatologist or other physician Seek advice/treatment from a hair stylist Use the advice of a relative or a friend Use over-the-counter remedies/products Get advice from the Internet Read self-help books Use home remedies/products I do not treat my hair problem I do not have hair problems or concerns Other Please specify Other?* (Be very specific. Can be based on your hair quality, hair density, hair diameter, hair length, how the hair behaves or how it looks.)About Yourself - WorkoutDo you workout on a regular basis (3 or more hours/week)?* Yes No During your workout, do you wear your hair pulled up (secured with hair accessories i.e., rubber band, barrettes, hair pins, clips, etc.)?* Yes No During your workout, do you wear your hair hanging down?* Yes No During your workout, do you sweat in your scalp?* Yes No During your workout, do you wear a headband to hold your hair back out of your face?* Yes No During your workout, do you wear a scarf?* Yes No About Yourself - SwimDo you swim on a regular basis (3 or more hours/week)? Yes No Do you wear a swim cap when you swim?* Yes No About Yourself - Outside SportsDo you participate in outside sports/where you can be out in the sun for over 10 hours/week on a regular basis?* Yes No Do you wear a hat, cap, or scarf when you participate in outside sports?* Yes No Do you wear a hat, cap, or scarf when you participate in outside sports?* Yes No What type of products are you willing to use?* Safe products that work to get my hair in the most desirable state Only products that are considered to be 'natural' Will you please describe what you would ultimately like to achieve with your hair?* HAIR TREATMENT: Hair ColorIs hair color used on your hair?* Yes No How was your hair color applied? (Please select based on your most recent application.)* Self-applied Professionally applied How often is hair color applied to your hair?* Every 1 to 3 weeks Every 1 to 2 months Every 3 to 5 months Every 6 to 8 months Every 9 to 12 months What specific brand was used on your hair? (Please select based on your most recent application. Write "don't know", if unsure.)* What specific color was used on your hair? (Please select based on your most recent application. Write "don't know", if unsure.)* Which options below best describes the type of hair color used? (Please select all that apply for your most recent application.)* Rinse Semi-permanent Permanent Highlights Lowlights Henna Don't know What was your reason(s) for getting hair color? (Please select all that apply based on your most recent application.)* To cover grey hair For fashion or to obtain a classy or unique look For shine Other Please specify Other?* HAIR TREATMENT: RelaxerDo you have a relaxer?* Yes No How was your relaxer applied? (Please select based on your most recent application.)* Self-applied Professionally applied How often is your hair relaxed?* Every 4 weeks or less Every 5 to 7 weeks Every 8 to 12 weeks Every 3 to 4 months Every 5 to 7 months Every 8 to 12 months Less than 1 time per year What specific brand of relaxer was used on your hair? (Please answer based on your most recent application. Write "don't know", if unsure.)* Which option below best describes the strength of your relaxer? (Please select based on your most recent application.)* Mild or for color treated Normal or medium strength Resistant or super strength Don't know What type of relaxer was used on your hair? (Please select based based on your most recent application.)* Lye based (usually a professional no-mix product) No-lye based (usually purchased over-the-counter and is a product that requires mixing) Don't know What was your reason(s) for getting a relaxer? (Please select all that apply based on your most recent application.)* For manageability/ease of combing Hair growth For a straight style To prevent frizz Other Please specify Other (Relaxer)?* HAIR TREATMENT: TexturizerDo you have a texturizer (a treatment that loosens the curl without completely straightening it)?* Yes No How was your texturizer applied? (Please select based on your most recent application.)* Self-applied Professionally applied How often is a texturizer applied to your hair?* Every 4 weeks or less Every 5 to 7 weeks Every 8 to 12 weeks Every 3 to 4 months Every 5 to 7 months Every 8 to 12 months Less than 1 time per year What specific brand of texturizer was used on your hair? (Please answer based on your most recent application. Write "don't know", if you are unsure.)* What type of texturizer was used on your hair? (Please select based based on your most recent application.)* Lye based (usually a professional no-mix product) No-lye based (usually purchased over-the-counter and is a product that requires mixing) Don't know What was your reason(s) for getting a texturizer? (Please select all that apply based on your most recent application.)* For manageability/ease of combing Hair growth For a straight style To prevent frizz Other Please specify Other (Texturizer)?* HAIR TREATMENT: Straightening TreatmentDo you have a Keratin or Brazilian straightening treatment?* Yes No What is the brand name of the Keratin or Brazilian straightening treatment used? (Please answer based on your most recent application. Write "don't know", if unsure.)* How often do you get the Keratin or Brazilian straightening treatment?* Every 1 to 3 weeks Every 1 to 2 months Every 3 to 5 months Every 6 to 8 months Every 9 to 11 months Every 12 to 18 months What was your reason(s) for getting the Keratin or Brazilian straightening treatment? (Please select all that apply based on your most recent application.)* For manageability/ease of combing Hair growth For a straight style To prevent frizz To have a temporary straightened look Other Please specify Other (Keratin or Brazilian)?* HAIR TREATMENT: Curly PermDo you have a curly perm such as Wave Nouveau, Care Free Perm, Iso Perm, etc?* Yes No What brand of curly perm treatment was used on your hair? (Please answer based on your most recent application. Write "don't know", if you are unsure.)* How often do you get the curly perm treatment?* Every 1 to 3 weeks Every 1 to 3 months Every 4 to 6 months Every 7 to 9 months Every 10 to 12 months Every 13 to 18 months What was your reason(s) for getting the curly perm treatment? (Please select all that apply based on your most recent application.)* For manageability/ease of combing Hair growth For loose-curled style Healthy hair Other Please specify Other (Curly Perm)?* HEAT PROCESSINGAre thermal appliances used on your hair? (This would include applying heat to the hair with a hooded dryer, blow dryer, flat iron, hot comb, etc.)* Yes No Please indicate the different ways your hair is heat processed.* Flat iron Curling iron Marcel irons Hot/pressing comb Blow dryer Hooded dryer Hot curling brush Hot rollers How often is your hair heat processed? (Please refer to the items listed above for a list of heat processing methods.)* More than once a day Once daily 4 to 6 days per week 2 to 3 days per week 1 time per week Every 2 to 3 weeks Every 4 to 5 weeks Every 6 to 8 weeks Every 9 to 12 weeks Every 3 to 4 months Every 5 to 6 months Every 6 to 12 months Less than 1 time per year Heat Processing - Blow DryerIs a blow dryer used on your hair?* Yes No What's the typical temperature setting on the blow dryer during use?* Low range temperature (300-350 oF or 149-177 oC) Medium range temperature (351-420 oF or 178-216 oC) High temperatures (over 420 oF or 216 oC ) Don't know Hair Processing - Hot Curling BrushIs a hot curling brush used on your hair?* Yes No How many times is the hot curling brush passed through your hair (per section)?* 1-2 3-4 5 or more Don't know What's the typical temperature setting on the hot curling brush during use?* Low range temperature (300-350 oF or 149-177 oC) Medium range temperature (351-420 oF or 178-216 oC) High temperatures (over 420 oF or 216 oC ) Don't know Hair Processing - Hot Curling IronIs a hot curling iron used on your hair?* Yes No How many times is the hot curling iron passed through your hair (per section)?* 1-2 3-4 5 or more Don't know What's the typical temperature setting on the hot curling iron during use?* Low range temperature (300-350 oF or 149-177 oC) Medium range temperature (351-420 oF or 178-216 oC) High temperatures (over 420 oF or 216 oC ) Don't know Hair Processing - Flat IronIs a flat iron used on your hair?* Yes No How many times is the flat iron passed through your hair (per section)?* 1-2 3-4 5 or more Don't know What's the typical temperature setting on the hot curling iron during use?* Low range temperature (300-350 oF or 149-177 oC) Medium range temperature (351-420 oF or 178-216 oC) High temperatures (over 420 oF or 216 oC ) Don't know HAIR REGIMENIf an item does not pertain to you, please write or choose 'None'.What is the name of the PRIMARY shampoo/cleansing product or agent used on your hair? (Please answer based on your most recent cleansing.)* What is the PRIMARY type of shampoo/cleansing product/agent used on your hair? (Please choose only one answer based on your most recent cleansing.)* 2 in 1 shampoo-conditioner Moisturizing Clarifying Volumizing Hydrating Smoothing For oily hair For normal hair For dry hair Dandruff/Medicated Other Please specify Other, PRIMARY type of shampoo/cleansing* If you use more than 1 shampoo, what is the name of the SECONDARY shampoo/cleansing product/agent used on your hair? (Please answer based on your most recent cleansing.)* What is the SECONDARY type of shampoo/cleansing product/agent used on your hair? (Please choose only one answer based on your most recent cleansing.)* None 2 in 1 shampoo-conditioner Moisturizing Clarifying Volumizing Hydrating Smoothing For oily hair For normal hair For dry hair Dandruff/Medicated Other Please specify Other, SECONDARY type of shampoo/cleansing* If you use more than 1 type of shampoo, what is the SECONDARY type of shampoo/cleansing product/agent used on your hair? (Please choose only one answer based on your most recent cleansing.)* None 2 in 1 shampoo-conditioner Moisturizing Clarifying Volumizing Hydrating Smoothing For oily hair For normal hair For dry hair Dandruff/Medicated How often is your hair cleansed?* Daily 4 to 6 days per week 2 to 3 days per week 1 time per week Every 2 to 3 weeks Every 4 to 5 times Every 6 to 8 weeks Every 2 to 3 months Every 4 to 6 months What is the name of the conditioner used after cleansing your hair? (Please answer based on your most recent cleansing.)* What "TYPE" of conditioner is used after cleansing your hair? (Please answer based on your most recent cleansing. Choose only one answer.)* None Rinse out Leave-in What is the "NAME" of the PRIMARY leave-in product used on your hair? (Please answer based on your most recent cleansing.)* What is the PRIMARY type of leave-in product used on your hair? (Please choose only one answer based on your most recent cleansing.)* None Oil Gel Cream Mousse Spritz Hair spray Serum Wax Pudding Hair honey Conditioner If you use more than 1 leave-in product, what is the name of the SECONDARY leave-in product used on your hair? (Please answer based on your most recent cleansing.)* What is the SECONDARY type of leave-in product used on your hair? (Please choose only one answer based on your most recent cleaning.)* None Oil Gel Cream Mousse Spritz Hair spray Serum Wax Pudding Hair honey Please examine these combs, consider the tooth spacing on the comb and not the brand, style or design. What type of comb do you use to style and manipulate your hair?* Wide-toothed Medium-toothed Fine-toothed None Please examine these brushes, consider the bristle type and not the brand, shape or design. What type of brush do you use to style and manipulate your hair? Natural Boar Plastic or Rubber Wood None What else do you use to style and manipulate your hair? (Select all that apply)* Fingers to twirl or rake through hair Pick Rollers Pin curls Other Please specify Other, (Style/Manipulate hair)* How often do you manipulate your hair? (Styling and manipulation includes combing, brushing, twirling or raking through with fingers, etc.) 3 or more times a day 1 or 2 times a day 4 to 7 times per week 1 to 3 times per week 1 to 4 times a month every 2 to 3 months every 4 to 6 months What is the usual state of your hair when you style or manipulate it? (Styling and manipulation includes combing, brushing, twirling or raking through with fingers, etc.) Wet Damp Completely Dry PhoneThis field is for validation purposes and should be left unchanged.
Please examine these brushes, consider the bristle type and not the brand, shape or design.
