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Dental Care Survey - Template

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1. My First Page

Q1. Do you presently have a dentist that you visit on a regular basis?

YesNo

Q2. How did you find your dentist?

Referral by friend / familyReferral by another dentistReferral by my companyAdvertisementCan't remember

Other (please specify) This field requires an answer.Please enter a comment.

Q3. The most common reason for not going to the dentist is:

I do go for regular check-upsThe cost of careI don't need to go very oftenI forget to goI don't like dentistsThere is nothing wrong with my teeth

I am scared! This field requires an answer.Please enter a comment.

Q4. Since when have you made regular visits to the current dentist?

< 1 year1-2 years2-3 years3-4 years4+ years

Q5. Do members of your household go to:

One dentistMore than one dentist

Q6. How often do you go to the dentist for checkups?

Every 6 monthsAt least once a yearAt least every 2 yearsAt least once every 3-4 yearsIt depends, I go when I have trouble with my teeth

Q7. Would you like your dentist to notify you when it is time for a check-up?

YesNoNot sure

Q8. How would you prefer to receive this notice?

Phone callSMSE-mail

Other (please specify) This field requires an answer.Please enter a comment.

Q9. What do you like best about your personal dentist?

Q10. What would you suggest that might make a visit to your dentist more pleasurable?

Debug Data (Page Randomization)
IsFromStart	Yes
Last Page Served	1
IsPageRandomizationApplied	InActive
Page Randomization Format	NA
Flip Page Format Direction	NA
Flip Survey Load Request Counter	0
Pages Loaded So Far (Progress)	1
Total Survey Pages (Progress)	1
Debug Data (Question Randomization)
Is Question Randomization Applied	False
Question Randomization Format	NA
Page Load Request Counter	0

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