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Oral Health Survey Questions + Sample Questionnaire Template

Learn more about the oral healthcare habits of your patients before your appointment and save time. Use this free oral healthcare survey template to know how health-conscious are they when it comes to teeth, gums, and overall oral care.

Use this sample dental and oral healthcare awareness questionnaire to know how people take care of their dental hygiene.

Based on the responses, oral health centers can understand current oral problems faced by people and what should be done to promote better oral hygiene.


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?
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
If you were unable to get oral health care, what was the reason?
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
How often during the last year, have you been self conscious or embarrassed because of your oral health problems?
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 satisfied are you with the health of the following?
Very Dissatisfied
Not satisfied
Neutral
Satisfied
Very Satisfied
Teeth
Gums
Tongue
Jaws
overall
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
What type of health care professional gave you an oral health check up?
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
Considering your knowledge about the benefits of oral health care, how likely are you to recommend it to your friend/colleague?
Very Unlikely
Very Likely

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