Tehama County Local Oral Health Community Survey Thank you for taking our survey. We value your feedback! Question Title * 1. How did you hear about this survey? OK Question Title * 2. In what ZIP code do you live? (enter 5-digit ZIP code) OK Question Title * 3. Please select your age 12 years and under 13-18 years 18-24 years 25-34 years 35-44 years 45-54 years 55-64 years 65 years and older I prefer not to say OK Question Title * 4. Please select your ethnicity Caucasian Hispanic or Latino African American Native American or American Indian Asian or Pacific Islander Other OK Question Title * 5. What is your annual income? $0-10,000 $10,000-25,000 $25,001-50,000 $50,000-75,000 $75,000 and up OK Question Title * 6. When was the last time you visited a dentist or dental clinic? Within last year 1-3 years 3-5 years > 5 years Never been I do not know OK Question Title * 7. During the past 12 months, did you or your family delay or not get dental care that you really needed? Yes No I do not know Other (please specify) OK Question Title * 8. If you could not get dental care during the past 12 months, what were the reasons that you could not get the dental care you needed? (Check all answers that apply.) No insurance Speak a different language Cost/expensive Afraid/Do not like dentists No time Insurance does not cover the services No transportation Could not get an appointment Didn't think it was important Other (please specify) OK Question Title * 9. Where do you and your family go for dental services? Nowhere Rolling Hills Dental Clinic Greenville Dental Clinic Northern Valley Indian Health Dental Clinic Corning Dental Clinic Private Dental Office Dental Clinic in another county Other (please specify) OK Question Title * 10. If you were able to see a dentist, how long is the wait for a dental appointment? < 30 days 30-60 days 60-90 days > 90 days OK Question Title * 11. What kind of dental insurance do you and your family have right now? Self-purchased dental insurance Dental insurance from my employer No dental insurance Denti-Cal/Medical OK Question Title * 12. How important do you feel your teeth are? Very important Fairly important Important Not important I do not know OK Question Title * 13. How would you describe the condition of your mouth and teeth? Healthy Fair Unhealthy I do not know OK Question Title * 14. Do you have any problems in your mouth such as loose teeth, red or swollen gums, difficulty chewing, poorly fitting dentures or other complications? Yes No If yes, please describe OK Question Title * 15. How often do you brush your teeth? Once a day Twice a day Sometimes Only when I remember OK Question Title * 16. Are you aware that Fluoride builds stronger teeth and protects them from cavities? Yes No I do not know OK Question Title * 17. Do you use any of the following tobacco products? (Check all that apply) Cigarettes E-Cigarettes Cigars Pipe Hookah Chewing Tobacco I do not smoke Other (please specify) OK If you have children, please complete the questions below: OK Question Title * 18. How old are your children? (enter age/ages) OK Question Title * 19. How long has it been since her/his last dental visit? Within last year 1-3 years 3-5 years > 5 years Never been I don't know OK Question Title * 20. If you could not get dental care for your child during the past 12 months, what were the reasons your child could not get the dental care she/he needed? (Check all answers that apply.) Dentist doesn't accept Medi-Cal No insurance Speak a different language Afraid/don't like dentists No time to take them to the dentist Could not get an appointment Insurance does not cover the services Cost/too expensive No transportation Other (please specify) OK Question Title * 21. Has your child/children been to a dentist with an emergency dental problem in the last 12 months? Yes No Other (please specify) OK Question Title * 22. Have you or your child ever been told you have diabetes? Yes No Other (please specify) OK Question Title * 23. Do you have any comments, concerns or questions about oral health you would like to share? OK Tehama County Public Health, 1860 Walnut St. Suite C Red Bluff, CA 96080 530-527-6824 or 800-655-6854 OK DONE