Request edit access
Oral Health Survey
If you are...
What is your race/ethnicity? (If applicable, you may choose more than one race or ethnicity.)
What is the highest level of education you have completed?
Which community issue is important to you? (check all that apply)
How would you rate your overall health and well being?
Where do you get information about health and wellness?
When you need health care, where do you usually go?
How would you rate the overall condition of your teeth and gums
How do you pay for your dental care?
If you do not have dental insurance, what is the reason for not having it?
When was the last time you visited a dental professional (dentist or dental hygienist)?
Where did you receive services for your last dental visit?
In the past 5 years which of the following oral health/mouth issues have you experienced?
Which of the answer choices below BEST describes how you take care of your teeth?
Which of the following statements about oral health services are TRUE for you? (check all that apply)
How often do you brush your teeth or have someone help you brush your teeth?
How often do you floss your teeth or have someone help you floss your teeth?
Do you use tobacco products?
How often do you consume soda, fruit juice or sports/energy drinks?
How often do you eat fruits and vegetables?
A child should go to the dentist before age 5.
Going to the dentist for a check-up is as important as going to the doctor for a checkup.
Taking care of my teeth is important for my overall health.
Cavities are preventable.
Brushing and flossing my teeth is important for keeping my mouth healthy.
I only go to the dentist when I have a toothache.
I believe regular dental check-ups will prevent dental problems.
I often avoid smiling because of my teeth.
The way my teeth and mouth look has made it hard for me to get a job.
I believe my race impacts my ability to access quality dental care.
I have a right to good dental care no matter how much I can pay.
NOTES
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms