Oral Health Screening
a. About how long has it been since you last visited a dentist? Include all types of dentists
such as orthodontists, oral surgeons, and all other dental specialists as well as dental
hygienists.
i.never have been
ii.more than 5 years ago
iii.more than 2 years, but not more than 5 years ago
iv.more than 1 year, but not more than 2 years ago
v.more than 6 months, but not more than a year
vi.6 months or less
b. How often during the past year have you had painful aching anywhere in your mouth?
Would you say…
i.very often
ii.fairly often
iii.occasionally
iv.hardly ever
v.never
c. Overall, how would you rate the health of your teeth and gums? Would you say…
i.poor
ii.fair
iii.good
iv.very good
v.excellent
d. How many times do you brush your teeth in one day?
i.0
ii.1
iii.2
iv.3
e. During the past 12 months, was there a time when you needed dental care but could
not get it at that time?
i.yes
ii.no (skip next question)
f. What were the reasons that you could not get the dental care you needed?
(mark all that apply)
i.could not afford the cost
ii.did not want to spend the money
iii.insurance did not cover recommended procedures
iv.dental office is too far away
v.dental office is not open at convenient times
vi.too busy
vii.another dentist recommended not doing it
viii.afraid or do not like dentists
ix.unable to take time off from work
x.I did not think anything serious was wrong/expected dental problems to go away
g. Physical Exam - Which of the following best describes your observations during the oral
exam?
i.severe tooth decay or abnormality
ii.moderate tooth decay or abnormality
iii.minimal/focal tooth decay or abnormality
iv.no visible tooth decay or abnormality
If positive exam for cavity or would like fluoride varnish application, refer to
oral health diagnosis and treatment station