Oral Hygiene Survey

We appreciate you helping us to serve you better by answering a few questions about your oral hygiene habits.

Completion of this survey will enter you into a raffle to win one of two electric toothbrushes or one of two AirFlossers.

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* 1. What type of toothbrush do you use?

Manual

Oral-B

Sonicare

Other Brand Electric Brush (Please list name in the comment field)

Other (please specify)

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* 2. How often per week do you use dental floss?

Everyday

Three to four times per week

Once per week

Rarely

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* 3. What other aids do you use to clean in-between your teeth? (check all that apply)

Piks

Interproximal brushes

Stimudents

Floss Threaders

None

Other (please specify)

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* 4. Do you use a WaterFlosser?

Yes

I am unfamiliar with WaterFlossers

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* 5. What Brand WaterFlosser?

WaterPik

AirFlosser

Other (please specify)

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* 6. What do want in a toothpaste? (select all that apply)

Flouride

Whitening

Tartar Control

Reduces sensitivity

Herbal

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* 7. Would you be interested in learning more about tooth whitening?

Yes

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* 8. Do you use mouthwash as a part of you oral hygiene routine?

Yes

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* 9. Are you aware that specific mouthwashes aid in maintaining your dental health by reducing the amount of bacteria in your mouth?

Yes

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* 10. We provide a Oral Hygiene kit at each Continuing Care visit. Please rate how useful you find the items we provide.

	Not Useful	Somewhat Useful	Useful	Very Useful
Toothbrush	Toothbrush Not Useful	Toothbrush Somewhat Useful	Toothbrush Useful	Toothbrush Very Useful
Floss	Floss Not Useful	Floss Somewhat Useful	Floss Useful	Floss Very Useful
Lip Balm	Lip Balm Not Useful	Lip Balm Somewhat Useful	Lip Balm Useful	Lip Balm Very Useful
Pouch	Pouch Not Useful	Pouch Somewhat Useful	Pouch Useful	Pouch Very Useful
Toothpaste	Toothpaste Not Useful	Toothpaste Somewhat Useful	Toothpaste Useful	Toothpaste Very Useful
Mouth Rinse	Mouth Rinse Not Useful	Mouth Rinse Somewhat Useful	Mouth Rinse Useful	Mouth Rinse Very Useful
Coupons	Coupons Not Useful	Coupons Somewhat Useful	Coupons Useful	Coupons Very Useful
Other Aids (proxabrush, etc.)	Other Aids (proxabrush, etc.) Not Useful	Other Aids (proxabrush, etc.) Somewhat Useful	Other Aids (proxabrush, etc.) Useful	Other Aids (proxabrush, etc.) Very Useful

Oral Hygiene Survey

Question Title

* 1. What type of toothbrush do you use?

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* 2. How often per week do you use dental floss?

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* 3. What other aids do you use to clean in-between your teeth? (check all that apply)

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* 4. Do you use a WaterFlosser?

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* 5. What Brand WaterFlosser?

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* 6. What do want in a toothpaste? (select all that apply)

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* 7. Would you be interested in learning more about tooth whitening?

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* 8. Do you use mouthwash as a part of you oral hygiene routine?

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* 9. Are you aware that specific mouthwashes aid in maintaining your dental health by reducing the amount of bacteria in your mouth?

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* 10. We provide a Oral Hygiene kit at each Continuing Care visit. Please rate how useful you find the items we provide.

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* 11. Name (for raffle entry)

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* 12. Email (for contact if you win the raffle)