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Oral Health Survey Questions + Sample Questionnaire Template

Oral health survey questions and examples can be used to obtain information about the oral health condition of the respondents, the oral health related behaviors, the factors that facilitate behaviors that are conducive to good oral health and barriers which prevent people from adopting positive behaviors. This sample survey can be customized according to the details required of the audience. A questionnaire such as this, can enable the oral health centers to understand the current oral health problems faced by the audience and appropriate decisions can be taken to promote better oral health accordingly.


Considering your knowledge about the benefits of oral health care, how likely are you to promote it to your friend/colleague?
Very Unlikely
Very Likely
How satisfied are you with the health of the following?
Very Dissatisfied
Not satisfied
Neutral
Satisfied
Very Satisfied
Teeth
Gums
Tongue
Jaws
overall
How often during the last year, have you had discomfort in the following parts of your mouth?
Very Often
Fairly often
Occasionally
Hardly Ever
Never
Teeth
Gums
Tongue
Jaws
When was the last time you got a oral health checkup?
What was the main reason for your last visit to a oral health care centre?
If you were unable to get oral health care, what was the reason?
How often during the last year, have you been self conscious or embarrassed because of your oral health problems?
Are you aware about the benefits or the importance of the following?
Yes
No
Don't Remember
Benefits of quitting cigarettes or other type of tobacco products
Benefits of checking your blood sugar?
Importance of examination for oral cancer
Have you visited an oral healthcare center for the following in the past 12 months?
Yes
No
Don't Remember
Treatment for gum disease such as scaling and deep cleaning
Treatment for teeth ever becoming loose without an injury
Treatment for any tissue abuse habit like using toothpicks or anything else
Treatment for any cavities in your teeth
What type of health care professional gave you an oral health check up?
What do you use for cleaning your teeth?
How often do you do the following?
Never
Once a day
Twice a day
More than twice a day
Brush your teeth
Use dental floss
Clean your tongue
Rinse your mouth
How much do you think the following factors increase the risk for oral health problems?
0%
100%
Eating a lot of sugar products
Not brushing teeth
Eating or drinking frequently
Not rinsing after a meal
Smoking or using tobacco based products

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