This free survey is powered by QUESTIONPRO.COM
  1. Surveys
  2. 2011
  3. July
  4. D
  5. Dental Status Needs Assessment
0%
Exit Survey »
 
 
Hello:
You are invited to participate in our survey Dental Health Needs. In this survey, Epilepsy Foundation of Florida (EFOF) seeks to perform a survey of its clients living in Miami-Dade, Broward, and Monroe Counties to assess their dental status and needs. You will be asked to complete a survey that asks questions about dental health needs, attitudes toward dental care and reasons preenting you from accessing care. It will take approximately twenty minutes to complete the questionnaire.

Your participation in this study is completely voluntary. There are no foreseeable risks associated with this project. However, if you feel uncomfortable answering any questions, you can withdraw from the survey at any point. It is very important for us to learn your opinions.

Your survey responses will be strictly confidential and data from this research will be reported only in the aggregate. Your information will be coded and will remain confidential. If you have questions at any time about the survey or the procedures, you may contact Jennifer Piña at (305) 670-4949 Ext. 221 or by E-mail at [email protected].

Thank you very much for your time and support. Please start with the survey now by clicking on the Continue button below.
 
 
 
How long has it been since your last visit for dental care?
 
Within past 12 months
 
1-2 years
 
3-5 years
 
More than 5 years
 
Never received dental care
 
 
 
What was the main reason for your last visit for dental care?
 
No visit
 
Regular checkup
 
To have teeth cleaned
 
To have teeth filled
 
To have teeth pulled or other surgery
 
Toothache
 
Adjustment or repair of a denture
 
To have a denture made
 
For a prescription
 
Bleeding gums or periodontal disease
 
Loose teeth
 
Accident or injury
 
Problems with 3rd molar (wisdom teeth)
 
Some other reason (please specify) ___________
 
 
 
During the past 12 months, how many times have you seen a dentist for preventive dental care, such as check-ups and dental cleanings?

 
1 to 2 times
 
3 or more times
 
Don’t know
 
Refused
 
 
 
During the past 12 months, have you had a dental problem which you would have liked to see a dentist about but you didn't see the dentist?

 
Yes
 
No
 
 
 
If yes, why didn't you see him? If no, skip and go to question 7.
 
You didn’t think it was important
 
You couldn’t afford treatments or you didn’t have insurance
 
The problem went away
 
You did not have transportation
 
You were afraid to see a dentist
 
You were waiting for an appointment
 
You didn’t think a dentist could fix the problem
 
 
 
Are you covered by any public or private insurance plan that would pay for any part of your dental bills? (Including Medicare or Medicaid)
 
Yes
 
No
 
 
 
Did any of these plans cover any part of dental care?
 
Yes
 
No
 
Don't know
 
 
 
Do you feel that you are currently in need of dental treatment?
 
Yes
 
No
 
 
 
If yes, how soon do you feel you need treatment?
 
Immediately
 
Within 6 months from now
 
More than 6 months from now
 
Not at all
 
Currently receiving treatment
 
Survey Software Powered by QuestionPro Survey Software