Prenatal Oral Health Survey Question Title * 1. How many pregnant patients do you see per month in your practice? None 1-3 4-7 7-10 10 or more Comments Question Title * 2. Mark each trimester in which you would provide the following services to pregnant women. First Trimester Second Trimester Third Trimester Any Trimester Exam Exam First Trimester Exam Second Trimester Exam Third Trimester Exam Any Trimester X-Rays X-Rays First Trimester X-Rays Second Trimester X-Rays Third Trimester X-Rays Any Trimester Cleaning Cleaning First Trimester Cleaning Second Trimester Cleaning Third Trimester Cleaning Any Trimester Periodontic Treatments Periodontic Treatments First Trimester Periodontic Treatments Second Trimester Periodontic Treatments Third Trimester Periodontic Treatments Any Trimester Crowns Crowns First Trimester Crowns Second Trimester Crowns Third Trimester Crowns Any Trimester Fillings Fillings First Trimester Fillings Second Trimester Fillings Third Trimester Fillings Any Trimester Root Canals Root Canals First Trimester Root Canals Second Trimester Root Canals Third Trimester Root Canals Any Trimester Extractions Extractions First Trimester Extractions Second Trimester Extractions Third Trimester Extractions Any Trimester Nitrous Oxide Nitrous Oxide First Trimester Nitrous Oxide Second Trimester Nitrous Oxide Third Trimester Nitrous Oxide Any Trimester Antibiotic Medication Antibiotic Medication First Trimester Antibiotic Medication Second Trimester Antibiotic Medication Third Trimester Antibiotic Medication Any Trimester Pain Medication Pain Medication First Trimester Pain Medication Second Trimester Pain Medication Third Trimester Pain Medication Any Trimester Comments Question Title * 3. What is your level of concern about liability when treating pregnant women? No Concerns Some Concern Major Concerns Please explain if you have concerns: Question Title * 4. What would help alleviate your concerns? Question Title * 5. Do you require written consent from a patient's OB or primary medical provider prior to caring for that pregnant patient? Yes No Sometimes, please explain Question Title * 6. Are you aware that in 2012, the American Dental Association (ADA) and American College of Obstetricians and Gynecologists (ACOG) developed National Guidelines for providing dental care and treatment to pregnant women? Yes No Question Title * 7. If yes, has your practice made any changes to the way(s) you manage and treat pregnant patients? Do more Do the same Do less I am not familiar with these guidelines Exams Exams Do more Exams Do the same Exams Do less Exams I am not familiar with these guidelines X-Rays X-Rays Do more X-Rays Do the same X-Rays Do less X-Rays I am not familiar with these guidelines Periodontal Treatment Periodontal Treatment Do more Periodontal Treatment Do the same Periodontal Treatment Do less Periodontal Treatment I am not familiar with these guidelines Crowns Crowns Do more Crowns Do the same Crowns Do less Crowns I am not familiar with these guidelines Fillings Fillings Do more Fillings Do the same Fillings Do less Fillings I am not familiar with these guidelines Root Canals Root Canals Do more Root Canals Do the same Root Canals Do less Root Canals I am not familiar with these guidelines Extractions Extractions Do more Extractions Do the same Extractions Do less Extractions I am not familiar with these guidelines Nitrous Oxide Nitrous Oxide Do more Nitrous Oxide Do the same Nitrous Oxide Do less Nitrous Oxide I am not familiar with these guidelines Antiobiotic Medication Antiobiotic Medication Do more Antiobiotic Medication Do the same Antiobiotic Medication Do less Antiobiotic Medication I am not familiar with these guidelines Pain Medication Pain Medication Do more Pain Medication Do the same Pain Medication Do less Pain Medication I am not familiar with these guidelines Comments Question Title * 8. A number of your local prenatal medical colleagues are interested in referring their pregnant patients to local dentists for care (including commercially insured, private pay, and/or Apple Health {Medicaid} clients) . Would you like your practice to be included on the referral list? If yes, please list your practice’s name and contact information. Yes No Practice Name and Contact Information Question Title * 9. What type of reimbursement for services do you accept? Commercial Insurance Cash/Payment Plans Apple Health (Medicaid) All of the above Comments? Question Title * 10. Are you interested in attending a free Continuing Dental Education course and dinner to learn more about the latest prenatal oral health guidelines and lack of liability for providing prenatal oral health care and treatment? Yes No Maybe Question Title * 11. Please include your information so that we can place your name in a drawing to win a $50 gift card! Name Company Address Address 2 City/Town State/Province ZIP/Postal Code Email Address Phone Number Done