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Your Smile, Your Say
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This quick 2-minute survey will help us know more about your oral health. Please answer these questions honestly.
How would you describe your dental health at the moment?
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Very good
Good
Fair
Bad
Very bad
Why do you feel this way about your dental health?
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(Select all that apply.)
My dentist/hygienist told me
I do not have mouth pain
I do not have cavities
I do not have gum disease
I do not have toothaches
I have mouth pain
I have or have had cavities recently
I have gum disease
My gums bleed when I brush my teeth
I have really bad breath
I have frequent toothaches
Other
You chose "Other", please specify:
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When was the last time you went to the dentist?
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In the last 6 months
About 7 to 12 months ago
Over 1 year ago
Over 2 years ago
Can’t remember
Never
What was the reason for your last dental visit?
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Routine appointment including checkup and cleaning
Follow-up appointment
Tooth/mouth pain
Something else
Can’t remember
Other
You chose "Other", please specify:
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If you have not visited the dentist in the past year, why not?
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I don’t need to see the dentist; I feel fine.
I have some concerns about seeing a dentist.
I’m concerned about affording appointments.
I didn’t have time.
I do not have a way to get there
I do not have a dentist
I forgot to go.
Not sure.
Other
You chose "Other", please specify:
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Are you experiencing any of the following oral health problems?
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(Select all that apply.)
Gum bleeding while brushing/flossing (two to four times per month or more)
Tooth sensitivity
Frequent tooth pain/aches
Loose, broken, or cracked teeth
Swollen or inflamed gums
Tartar/plaque buildup
Frequent dry mouth
Bad breath
Oral pain
Bumps or lesions in the mouth (granulomas)
Other oral health issue
None of these
Please rate the severity of the gum bleeding you’re experiencing on a scale of 1 to 10.
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(1 = Minor gum bleeding; 10 = Extreme gum bleeding)
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10
Please rate the severity of the tooth sensitivity you’re experiencing on a scale of 1 to 10.
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(1 = Minor gum sensitivity; 10 = Extreme gum sensitivity)
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10
Please rate the severity of the gum swelling/inflammation you’re experiencing on a scale of 1 to 10.
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(1 = Minor swelling or inflammation; 10 = Severe swelling or inflammation)
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10
Please rate the severity of your bad breath on a scale of 1 to 10.
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(1= Minor bad breath; 10 = Severe bad breath)
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10
Please rate the severity of your oral pain on a scale of 1 to 10.
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(1= Minor oral pain; 10 = Severe oral pain)
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10
You chose "Other", please specify:
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Please rate the severity of the oral health issue you’re experiencing on a scale of 1 to 10.
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(1 = Minor; 10 = Extreme)
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10
Have you ever heard of a possible relationship between oral health and diabetes?
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Yes
No
Where did you hear this?
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I saw it online, in a book, or a magazine.
My doctor told me.
My dentist/hygienist told me.
Friends/relatives told me.
I experienced this.
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