COHI Better Oral Health Survey (English)

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* 4. What is the highest degree or level of school you have completed?

Did not complete high school

Completed high school, G.E.D, or equivalent

Attending College/University

Attended, but did not compete college/university

Completed College/University degree

Post-graduate degree

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* 5. Do you identify as? (Check all that apply)

Female

Male

Transgender

Non-binary

Prefer not to answer

Other (please specify)

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* 6. Are you currently working? (Check one that best applies to you)

Full-time

Part-time

Unable to work

Unemployed

Retired

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* 7. What is your annual household income?

$0 to $29k

$30K to $49K

$50K to $69K

$70K+

I do not know

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* 8. Which category best describes you? (Check all that apply)

Black or African-American

Hispanic, Latino, or Spanish origin

White/Caucasian

Asian/Pacific Islander

American Indian, Alaskan Native, Indigenous, etc.

Other (please specify)

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* 9. How many people live in your household, including yourself?

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* 10. How many children, 21 and under, are currently living with you?

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* 11. What type of insurance do you currently have?

Medicaid/HUSKY

Private insurance through work

Private insurance purchased separate from work

Other (please specify)

None

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* 12. Where do you usually go for dental care? (Choose only one)

Private dentist office

Emergency Room

Wherever I can find a dentist

Community Health Center

I do not usually go anywhere

Other (please specify)

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* 13. If you answered "private dentist office" where do you go? (If not, SKIP this question)

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* 14. When was the last time you visited a dentist?

Within the last year (12 months)

More than a year ago

I do not remember the last time I went to the dentist

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* 15. The last time you saw a dentist, why did you go? (Check what applies to you)

Emergency Care

Annual checkup or Regular checkup (example: visit every 6 months)

Treatment (example: filling a cavity, getting a crown, removing a tooth, etc.)

Other (please specify)

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* 16. How satisfied were you with your last dental visit?

Very satisfied

Somewhat satisfied

Neither satisfied nor dissatisfied

Somewhat dissatisfied

Very dissatisfied

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* 17. How would you rate your oral health?

Good

Fair

Poor

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* 18. What makes it difficult for you to obtain the dental care that you need? (Check all that apply)

I cannot find a dentist

I cannot find a dentist that accepts my insurance

I cannot find transportation

I do not have child care while I go to the dentist

Dentist office hours conflict with my personal schedule

Wait times are too long for an appointment

The dentist office does not offer the procedures I need

I am afraid of going to the dentist

Procedure needed is not covered by insurance

Complications due to COVID-19 or other illness/disability

I reached the $1,000 HUSKY annual benefits cap

I cannot find a dentist's office that will take my children and me at the same time

I do not have insurance

I do not have difficulty finding the dental care I need

Other (please specify)

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* 19. How many times a day do you floss your teeth?

Less than once a day

Once a day

More than once a day

I do not floss my teeth

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* 20. How often do you brush your teeth?

Less than once a day

Once a day

Twice a day

More than twice a day

I do not brush my teeth

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* 21. Do you have any pain or bleeding in the gums and/or mouth?

Yes

COHI Better Oral Health Survey (English)

This survey will take approximately 5 minutes to complete.

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* 1. Where are you taking this survey?

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* 2. What town or city do you live in?

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* 3. What is your age?

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* 4. What is the highest degree or level of school you have completed?

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* 5. Do you identify as? (Check all that apply)

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* 6. Are you currently working? (Check one that best applies to you)

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* 7. What is your annual household income?

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* 8. Which category best describes you? (Check all that apply)

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* 9. How many people live in your household, including yourself?

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* 10. How many children, 21 and under, are currently living with you?

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* 11. What type of insurance do you currently have?

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* 12. Where do you usually go for dental care? (Choose only one)

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* 13. If you answered "private dentist office" where do you go? (If not, SKIP this question)

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* 14. When was the last time you visited a dentist?

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* 15. The last time you saw a dentist, why did you go? (Check what applies to you)

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* 16. How satisfied were you with your last dental visit?

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* 17. How would you rate your oral health?

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* 18. What makes it difficult for you to obtain the dental care that you need? (Check all that apply)

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* 19. How many times a day do you floss your teeth?

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* 20. How often do you brush your teeth?

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* 21. Do you have any pain or bleeding in the gums and/or mouth?