Patient has more than 10 teeth
Patient has 10 or fewer teeth
1. Place of birth (city, state) ..................................
2. How often do you see a dentist?
a. Twice a year or more
b. Once a year
c. Only when I have a problem like pain
d. Only when absolutely necessary, almost never
3. Have you ever gone for five years or more without seeing a dentist?
a. Yes
b. No
4. Describe your diet: (check as many as apply)
a. Lots of basic food groups: meat, vegetables, grains, and fruit
b. Lots of convenience foods like frozen dinners or packaged meals
c. I have a sweet tooth and snack on sweets at least once a day
d. I drink regular (non-diet) sodas at least once a day
e. I chew regular gum (not sugar free)
f. I suck on hard candy, cough drops, or breath mints at least once a day
5. Describe your exercise pattern:
a. I exercise for at least twenty minutes three times a week or more
b. I walk or take the stairs when I get a chance
c. I have a desk job or similar employment and don’t exercise much
d. I am very limited in what I can do for exercise so don’t move much
Survey
IMPACT OF ATTITUDES AND BEHAVIORS ON TOOTH LOSS
6. Describe your employment:
a. I am employed full time and have been for most of my life
b. I work part time and have done so for most of my life
c. I am retired after working full time for most of my life
d. I am retired after working part time for most of my life
e. I worked off and on for most of my life
f. I have been a full time homemaker for most of my life
7. Describe any habits that you may have: (circle as many as apply)
a. Smoke cigarettes
b. Smoke pipe or cigar
c. Use smokeless tobacco
d. Have used methamphetami nes or cocaine
e. Grind my teeth at night
f. Clench my teeth during the day
8. Describe your alcohol use:
a. Use daily, one or more glasses
b. Use weekly
c. Use at parties, socially
d. Rarely use, if ever
e. Do not consume alcohol at all.
9. Describe your parents: (check as many as apply)
a. They have/ had most or all of their teeth
b. They have lost many of their teeth
c. They wear/ wore partial dentures
d. They wear/ wore complete dentures
10. Describe your children: (check as many as apply)
a. They have most or all of their teeth
b. They have lost many of their teeth
c. They wear partial dentures
d. They wear complete dentures
11. Describe your home care habits: (check as many as apply)
a. I brush and floss twice a day
b. I brush and floss once a day
c. I brush twice a day
d. I brush once a day
e. I do not brush my teeth regularly
f. I use aids like rubber tip stimulators, toothpicks, perio aids, proxabrushes, or stimudents
12. My teeth are ............................................... to me:
a. Essential
b. Very important
c. Somewhat important
d. Not very important
e. Not at all important
13. What were your average earnings during the 1970’s?
............................................................................ per year
14. Why do you think that most people lose their teeth?
a. Soft teeth
b. No dentist available
c. Not important to some people
d. Poor brushing
e. Lack of money
15. What year were you born?
..............................................................................
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