Wellness Survey

Please take the following survey regarding your personal dental habits.


A red asterisk (*) indicates required questions.

  1. How often do you brush your teeth?*
    less than once per day
    once per day
    twice per day
    more than twice per day


  1. How often do you floss?*
    less than oncer per week
    once per week
    2-6 times per week
    once daily
    more than once per day


  1. When was your last dental check-up?*
    never had a check-up
    more than 3 years ago
    1-3 years ago
    in the last 12 months
    in the last 6 months


  1. What is the primary reason you have not visited the dentist more recently?*
    lack of insurance
    fear of dentists
    cost
    no problems/not necessary
    other


  1. How many times have you been to the dentist in the past two years other than for routine exams and cleaning?*
    none
    1 or 2 times
    3 or 4 times
    5 or more times


  1. Which of the following dental procedures have you had done in the past two years?*
    fillings for cavities
    crowns
    extraction (tooth pulled)
    root canal
    treatment for gum disease
    cosmetic dental procedure
    implants
    bridges
    dentures
    other
    none


  1. If you have children, how often do your children visit the dentist for routine cleanings and exams?*
    no children
    have not visited a dentist
    less than once per year
    once per year
    2 times per year
    more than 2 times per year


  1. Do you use tobacco?*
    Yes
    No


  1. Are you pregnant?*
    Yes
    No


  1. Do you have any of the following conditions?*
    Heart Disease
    Respiratory Conditions such as Chronic Obtrusive Pulmonary Disease (COPD)
    Diabetes
    Dementia
    Kidney Disease
    N/A




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