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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.

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When was the last time you got a oral health checkup?

3 months or less

More than 3 months but less than a year

More than a year but less than 2 years

More than 2 years but less than 5 years

More than 5 years

Never have been

What was the main reason for your last visit to a oral health care centre?

For a regular check up

It was mandatory for my office

Something was wrong or hurting

Went in for a follow-up

Other

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	Very Often	Fairly often	Occasionally	Hardly Ever	Never

Gums	Very Often	Fairly often	Occasionally	Hardly Ever	Never

Tongue	Very Often	Fairly often	Occasionally	Hardly Ever	Never

Jaws	Very Often	Fairly often	Occasionally	Hardly Ever	Never

If you were unable to get oral health care, what was the reason?

Could not afford

Insurance does not cover oral health care

Oral health care center is too far

Did not have the time

Were afraid to go

I got oral health care when needed

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	Yes	No	Don't Remember

Treatment for teeth ever becoming loose without an injury	Yes	No	Don't Remember

Treatment for any tissue abuse habit like using toothpicks or anything else	Yes	No	Don't Remember

Treatment for any cavities in your teeth	Yes	No	Don't Remember

How often during the last year, have you been self conscious or embarrassed because of your oral health problems?

Very Often

Fairly often

Occasionally

Hardly Ever

Never

What do you use for cleaning your teeth?

Floss only

Brush and toothpaste

Brush, toothpaste and floss

Other

How often do you do the following?

	Never	Once a day	Twice a day	More than twice a day
Brush your teeth	Never	Once a day	Twice a day	More than twice a day

Use dental floss	Never	Once a day	Twice a day	More than twice a day

Clean your tongue	Never	Once a day	Twice a day	More than twice a day

Rinse your mouth	Never	Once a day	Twice a day	More than twice a day

How satisfied are you with the health of the following?

	Very Dissatisfied	Not satisfied	Neutral	Satisfied	Very Satisfied
Teeth	Very Dissatisfied	Not satisfied	Neutral	Satisfied	Very Satisfied

Gums	Very Dissatisfied	Not satisfied	Neutral	Satisfied	Very Satisfied

Tongue	Very Dissatisfied	Not satisfied	Neutral	Satisfied	Very Satisfied

Jaws	Very Dissatisfied	Not satisfied	Neutral	Satisfied	Very Satisfied

overall	Very Dissatisfied	Not satisfied	Neutral	Satisfied	Very Satisfied

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	Yes	No	Don't Remember

Benefits of checking your blood sugar?	Yes	No	Don't Remember

Importance of examination for oral cancer	Yes	No	Don't Remember

What type of health care professional gave you an oral health check up?

Doctor/physician

Nurse

Dentist

Other

How much do you think the following factors increase the risk for oral health problems?

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

use this free template

Oral Health Survey Questions + Sample Questionnaire Template

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