Thank you for taking our survey. We value your feedback!

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* 1. How did you hear about this survey?

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* 2. In what ZIP code do you live? (enter 5-digit ZIP code)

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* 3. Please select your age

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* 4. Please select your ethnicity

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* 5. What is your annual income?

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* 6. When was the last time you visited a dentist or dental clinic?

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* 7. During the past 12 months, did you or your family delay or not get dental care that you really needed?

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* 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.)

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* 9. Where do you and your family go for dental services?

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* 10. If you were able to see a dentist, how long is the wait for a dental appointment?

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* 11. What kind of dental insurance do you and your family have right now?

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* 12. How important do you feel your teeth are?

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* 13. How would you describe the condition of your mouth and teeth?

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* 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?

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* 15. How often do you brush your teeth?

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* 16. Are you aware that Fluoride builds stronger teeth and protects them from cavities?  

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* 17. Do you use any of the following tobacco products? (Check all that apply)

If you have children, please complete the questions below:

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* 18. How old are your children? (enter age/ages)

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* 19. How long has it been since her/his last dental visit?

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* 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.)

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* 21. Has your child/children been to a dentist with an emergency dental problem in the last 12 months?

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* 22. Have you or your child ever been told you have diabetes?

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* 23. Do you have any comments, concerns or questions about oral health you would like to share?

Tehama County Public Health, 1860 Walnut St. Suite C Red Bluff, CA 96080 530-527-6824 or 800-655-6854

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