Oral Health Needs Assessment of Cancer Patient by Health Professionals Survey

1. Oral Health Needs Assessment of Cancer Patient by Health Professionals

The purpose of the following survey is to assess the oral health needs of people living with cancer and to provide feedback about the OHCCP website.

This survey is voluntary and you may elect not to participate. Your completion of the survey, in whole or in part, indicates your willingness to participate and will serve as consent. There is no compensation for participating and there are no risks or benefits associated with completing the survey. Your answers are kept confidential and your responses will not be name linked to any summary information.

All collective information will exclusively be used for purposes of web development only.

1. Age of patient

Age of patient

2. Sex of patient

Sex of patient Male

Female

Transgender

3. Location of patient

Location of patient City/Town:
State/Province:
Country:

4. Please choose your highest level of education completed, job title, and average number of cancer patients seen per month from the drop down menus below.

	ow many years of school did you complete?	What is your job title?	On average, how many cancer patients do you see per month that are actively receiving cancer therapy?
ducation and Professional Information	Please choose your highest level of education completed, job title, and average number of cancer patients seen per month from the drop down menus below. ducation and Professional Information ow many years of school did you complete?	What is your job title?	On average, how many cancer patients do you see per month that are actively receiving cancer therapy?

Other job title (please specify)

5. Due to chemotherapy and/or radiation therapy, my cancer patients generally present with the following conditions (please specify how many times per month you see a cancer patient with the following conditions):

	1 patient/month	2-5 patients/month	6-10 patients/month	11-15 patients/month	16-20 patients/month	20+ patients/month
mucositis	*Due to chemotherapy and/or radiation therapy, my cancer patients generally present with the following conditions (please specify how many times per month you see a cancer patient with the following conditions): mucositis 1 patient/month	mucositis 2-5 patients/month	mucositis 6-10 patients/month	mucositis 11-15 patients/month	mucositis 16-20 patients/month	mucositis 20+ patients/month
painful mouth and gums	painful mouth and gums 1 patient/month	painful mouth and gums 2-5 patients/month	painful mouth and gums 6-10 patients/month	painful mouth and gums 11-15 patients/month	painful mouth and gums 16-20 patients/month	painful mouth and gums 20+ patients/month
oral and systemic infections	oral and systemic infections 1 patient/month	oral and systemic infections 2-5 patients/month	oral and systemic infections 6-10 patients/month	oral and systemic infections 11-15 patients/month	oral and systemic infections 16-20 patients/month	oral and systemic infections 20+ patients/month
xerostomia	xerostomia 1 patient/month	xerostomia 2-5 patients/month	xerostomia 6-10 patients/month	xerostomia 11-15 patients/month	xerostomia 16-20 patients/month	xerostomia 20+ patients/month
rampant tooth decay	rampant tooth decay 1 patient/month	rampant tooth decay 2-5 patients/month	rampant tooth decay 6-10 patients/month	rampant tooth decay 11-15 patients/month	rampant tooth decay 16-20 patients/month	rampant tooth decay 20+ patients/month
burning, peeling or swelling tongue	burning, peeling or swelling tongue 1 patient/month	burning, peeling or swelling tongue 2-5 patients/month	burning, peeling or swelling tongue 6-10 patients/month	burning, peeling or swelling tongue 11-15 patients/month	burning, peeling or swelling tongue 16-20 patients/month	burning, peeling or swelling tongue 20+ patients/month
stiffness in the jaw	stiffness in the jaw 1 patient/month	stiffness in the jaw 2-5 patients/month	stiffness in the jaw 6-10 patients/month	stiffness in the jaw 11-15 patients/month	stiffness in the jaw 16-20 patients/month	stiffness in the jaw 20+ patients/month
impaired ability to eat, speak or swallow	impaired ability to eat, speak or swallow 1 patient/month	impaired ability to eat, speak or swallow 2-5 patients/month	impaired ability to eat, speak or swallow 6-10 patients/month	impaired ability to eat, speak or swallow 11-15 patients/month	impaired ability to eat, speak or swallow 16-20 patients/month	impaired ability to eat, speak or swallow 20+ patients/month
change in ability to taste	change in ability to taste 1 patient/month	change in ability to taste 2-5 patients/month	change in ability to taste 6-10 patients/month	change in ability to taste 11-15 patients/month	change in ability to taste 16-20 patients/month	change in ability to taste 20+ patients/month
poor diet because of problems eating	poor diet because of problems eating 1 patient/month	poor diet because of problems eating 2-5 patients/month	poor diet because of problems eating 6-10 patients/month	poor diet because of problems eating 11-15 patients/month	poor diet because of problems eating 16-20 patients/month	poor diet because of problems eating 20+ patients/month
osteonecrosis of the jaw	osteonecrosis of the jaw 1 patient/month	osteonecrosis of the jaw 2-5 patients/month	osteonecrosis of the jaw 6-10 patients/month	osteonecrosis of the jaw 11-15 patients/month	osteonecrosis of the jaw 16-20 patients/month	osteonecrosis of the jaw 20+ patients/month
hyposalivary function	hyposalivary function 1 patient/month	hyposalivary function 2-5 patients/month	hyposalivary function 6-10 patients/month	hyposalivary function 11-15 patients/month	hyposalivary function 16-20 patients/month	hyposalivary function 20+ patients/month
candidaisis	candidaisis 1 patient/month	candidaisis 2-5 patients/month	candidaisis 6-10 patients/month	candidaisis 11-15 patients/month	candidaisis 16-20 patients/month	candidaisis 20+ patients/month
gingivitis	gingivitis 1 patient/month	gingivitis 2-5 patients/month	gingivitis 6-10 patients/month	gingivitis 11-15 patients/month	gingivitis 16-20 patients/month	gingivitis 20+ patients/month
periodontitis	periodontitis 1 patient/month	periodontitis 2-5 patients/month	periodontitis 6-10 patients/month	periodontitis 11-15 patients/month	periodontitis 16-20 patients/month	periodontitis 20+ patients/month
sialadentitis	sialadentitis 1 patient/month	sialadentitis 2-5 patients/month	sialadentitis 6-10 patients/month	sialadentitis 11-15 patients/month	sialadentitis 16-20 patients/month	sialadentitis 20+ patients/month
fissured tongue	fissured tongue 1 patient/month	fissured tongue 2-5 patients/month	fissured tongue 6-10 patients/month	fissured tongue 11-15 patients/month	fissured tongue 16-20 patients/month	fissured tongue 20+ patients/month

6. Due to chemotherapy and/or radiation therapy, my cancer patients generally need/have needed the following treatments (please specify how many times per month you see a cancer patient that needs/has needed the following treatments):

	1 patient/month	2-5 patients/month	6-10 patients/month	11-15 patients/month	16-20 patients/month	20+ patients/month
Cleaning	*Due to chemotherapy and/or radiation therapy, my cancer patients generally need/have needed the following treatments (please specify how many times per month you see a cancer patient that needs/has needed the following treatments): Cleaning 1 patient/month	Cleaning 2-5 patients/month	Cleaning 6-10 patients/month	Cleaning 11-15 patients/month	Cleaning 16-20 patients/month	Cleaning 20+ patients/month
Fluoride treatments	Fluoride treatments 1 patient/month	Fluoride treatments 2-5 patients/month	Fluoride treatments 6-10 patients/month	Fluoride treatments 11-15 patients/month	Fluoride treatments 16-20 patients/month	Fluoride treatments 20+ patients/month
Filling(s)	Filling(s) 1 patient/month	Filling(s) 2-5 patients/month	Filling(s) 6-10 patients/month	Filling(s) 11-15 patients/month	Filling(s) 16-20 patients/month	Filling(s) 20+ patients/month
Crown(s)	Crown(s) 1 patient/month	Crown(s) 2-5 patients/month	Crown(s) 6-10 patients/month	Crown(s) 11-15 patients/month	Crown(s) 16-20 patients/month	Crown(s) 20+ patients/month
Extraction(s)	Extraction(s) 1 patient/month	Extraction(s) 2-5 patients/month	Extraction(s) 6-10 patients/month	Extraction(s) 11-15 patients/month	Extraction(s) 16-20 patients/month	Extraction(s) 20+ patients/month
Endodontic therapy	Endodontic therapy 1 patient/month	Endodontic therapy 2-5 patients/month	Endodontic therapy 6-10 patients/month	Endodontic therapy 11-15 patients/month	Endodontic therapy 16-20 patients/month	Endodontic therapy 20+ patients/month
Scaling/root planing	Scaling/root planing 1 patient/month	Scaling/root planing 2-5 patients/month	Scaling/root planing 6-10 patients/month	Scaling/root planing 11-15 patients/month	Scaling/root planing 16-20 patients/month	Scaling/root planing 20+ patients/month
Periodontal maintenance	Periodontal maintenance 1 patient/month	Periodontal maintenance 2-5 patients/month	Periodontal maintenance 6-10 patients/month	Periodontal maintenance 11-15 patients/month	Periodontal maintenance 16-20 patients/month	Periodontal maintenance 20+ patients/month
Debridement	Debridement 1 patient/month	Debridement 2-5 patients/month	Debridement 6-10 patients/month	Debridement 11-15 patients/month	Debridement 16-20 patients/month	Debridement 20+ patients/month
Bridge	Bridge 1 patient/month	Bridge 2-5 patients/month	Bridge 6-10 patients/month	Bridge 11-15 patients/month	Bridge 16-20 patients/month	Bridge 20+ patients/month
Implant	Implant 1 patient/month	Implant 2-5 patients/month	Implant 6-10 patients/month	Implant 11-15 patients/month	Implant 16-20 patients/month	Implant 20+ patients/month
Complete denture - maxillary	Complete denture - maxillary 1 patient/month	Complete denture - maxillary 2-5 patients/month	Complete denture - maxillary 6-10 patients/month	Complete denture - maxillary 11-15 patients/month	Complete denture - maxillary 16-20 patients/month	Complete denture - maxillary 20+ patients/month
Complete denture - mandibular	Complete denture - mandibular 1 patient/month	Complete denture - mandibular 2-5 patients/month	Complete denture - mandibular 6-10 patients/month	Complete denture - mandibular 11-15 patients/month	Complete denture - mandibular 16-20 patients/month	Complete denture - mandibular 20+ patients/month
Complete denture - full	Complete denture - full 1 patient/month	Complete denture - full 2-5 patients/month	Complete denture - full 6-10 patients/month	Complete denture - full 11-15 patients/month	Complete denture - full 16-20 patients/month	Complete denture - full 20+ patients/month

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1. Oral Health Needs Assessment of Cancer Patient by Health Professionals

Oral Health Needs Assessment of Cancer Patient by Health Professionals
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