S.A.N.D.S.

In order to make the Special Needs Directory as useful as possible for all involved, we ask that you take a few moments to answer a handful of simple questions. Please indicate in the survey below whether or not you treat patients with mild manifestations of a specific condition. And, there too, if you treat patients with moderate manifestations of the same conditions.

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* 1. Are you adding a new listing, updating an existing record, or removing a record? If removing or updating an existing record, please fill out: Name (Question 2) and Organization Name (Question 9); and any other fields that need to be updated.

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* 2. Full Name (Last, First):

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* 3. Gender:

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* 4. Age:

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* 5. Dental school from which you graduated:

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* 6. Year of graduation: (YYYY)

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* 7. Did you participate in Post Graduate training?

  Yes No
Please chose from the following options:

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* 8. Do you have any additional Special Needs training/experience? If so, please explain:

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* 9. Office Name (If applicable):

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* 10. What county (or counties) do you serve?

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* 11. Office address:

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* 12. City and State:

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* 13. Zip Code:

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* 14. Office phone number, including area code:

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* 15. Office Website URL (If applicable):

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* 16. Email address (will not be listed on database; only used for contact purposes):

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* 17. If you are currently not treating patients with Special Needs, why not? (Please check all that apply):

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* 18. What resources could MUSC provide to assist and/or encourage you to treat patients with Special Needs in your practice? (Please check all that apply):

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* 19. In your dental practice, you provide care for:

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* 20. Is your practice a dental speciality practice?

  Yes No
please choose from one of the following options:

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* 21. Do you treat patients with the following conditions?  If so, what manifestation (check both columns if you see mild and moderate/severe conditions)?

  No, do not see these patients Mild Conditions Moderate/Severe Conditions
Cerebral Palsy
Down Sydrome
Autism Spectrum Disorders (Classic Autism, Asperger syndrome)
Hearing and Sight Impaired
Intellectual Disability
Medically Complex
Behavior/Learning Disorders (ADD, ADHD)
Parkinson's Disease
Traumatic Brain Injury
Alzheimer's/Dementia

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* 22. Do you use any of the following? (Please check all that apply.)

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* 23. Do you accept Medicaid payment?

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* 24. Do you accept new patients?

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* 25. Languages, in addition to English, that are used in your office:

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