After four weeks
survey for caregivers

Please complete the survey by circling your most appropriate response for each comment.

A.        The solution was easy to use.
                1-Strongly Disagree  2-Disagree  3-Neutral  4- Agree  5-Strongly agree

B.        The solution was convenient to use.
                1-Strongly Disagree  2-Disagree  3-Neutral  4-Agree  5-Strongly agree

C.        I found the solution to be flavorful and acceptable.
                1-Strongly Disagree  2-Disagree  3-Neutral  4-Agree  5-Strongly agree

D.        The solution did not cause gastric reactions.
                1-Strongly Disagree  2-Disagree  3-Neutral  4-Agree    5-Strongly agree

E.        The use of the liquid solution improved my oral condition.
                1-Strongly Disagree  2-Disagree  3-Neutral  4-Agree  5-Strongly agree

F.        I was happier and more confident about my oral health.
                1-Strongly Disagree  2-Disagree  3-Neutral  4-Agree  5-Strongly agree

G.        I experienced clean, smooth teeth and fresh breath.
                1-Strongly Disagree  2-Disagree  3-Neutral  4-Agree  5-Strongly agree

H.        The solution improved tooth, gum and oral tissue health.
                1-Strongly Disagree  2-Disagree  3-Neutral  4-Agree  5-Strongly agree

I.        The solution was more effective than the traditional toothpaste.
                1-Strongly Disagree  2-Disagree  3-Neutral  4-Agree  5-Strongly agree

J.        The use of the liquid solution and the trial protocol reduced the caregiver’s time to
    less than five minutes per brushing.
                1-Strongly Disagree  2-Disagree  3-Neutral  4-Agree  5-Strongly agree

Additional Comments:    

Name: _______________________

City: ____________________  and State: ______

The Cloonan Corporation     1440 Grand Avenue, Suite D,     San Marcos, CA 92078
Phone (760) 891-0078                                                  www.theanswer2oralcare.com