Surveyonics - Online Survey Software

Dental Care - Evaluating Attitudes and Measuring Patient Experience
For your convenience and ease of reference, we have created a template of Dental Care Survey. You can use this template as such or modify it to suit your needs. Alternatively, you can design your own survey from scratch.

 Question: How would you rate the health of your teeth/gums?
Excellent
Very good
Good
Fair
Poor
 Question: If you have gone for a cosmetic dental treatment, which one was it?
 Question: How satisfied are you with the overall quality of dental care you have received from your dentist?
Very Satisfied
Somewhat satisfied
Neutral
Somewhat dissatisfied
Very dissatisfied
 Question: Have you ever gone for a cosmetic dental treatment?
Yes
No
 Question: When was your last visit to a dentist?
Less than six months ago
Less than one year ago
Over a year ago
Over two years ago
Never
 Question: What difficulty did you face in choosing a good dentist?
 Question: In case you faced any difficulty in that procedure, please specify.
 Question: What according to you is the best way to find a good dentist?
 Question: How much importance do you give to various factors before choosing a dental care facility?
Very importantSomewhat importantNot sureNot important
Skill of the dentist/hygienist
Cost of services
Courteous and helpful staff
Effectiveness in pain management
Supply of information about benefits of new and improved technology
Assistance in getting insurance claims
Location of the dental office
Use of latest technology and equipments
 Question: Did you face any difficulty in choosing a good dentist?
None
Very few
Few
Many
 Question: Which age group do you belong to?
Below 20
21 to 30
31 to 40
41 to 60
61 to 80 and above
 Question: Where do you prefer going for dental care?
Private dental office
Health centre/Community clinic
Hospital outpatient department
 Question: For what reason(s) did you last visit your dentist?
Regular check up
Cleaning
Tooth or gum problem
Dentures
Braces

Any other, please specify
 Question: What are the barriers you face in seeing a dentist as often as is needed?
You are nervous to visit a dentist
Some of the dentists you want to see don't accept your insurance
You don't find the dentist you visit competent enough
Scheduling an appointment with your dentist is difficult
The wait at the clinic is very long
You don't have a health plan with dental benefits
 Question: Are you satisfied with the kind of dental care you received at the hands of your dentist?
Yes
No
 Question: How many times have you visited a dentist in last one year?
Never
Once
Twice
Thrice
More than 3 times