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1. Which age group do you belong to?
Below 20
21 to 30
31 to 40
41 to 60
61 to 80 and above
2. What difficulty did you face in choosing a good dentist?
3. 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
4. Do you own a pet?
True
False
5. For what reason(s) did you last visit your dentist?
Regular check up
Cleaning
Tooth or gum problem
Dentures
Braces
Any other, please specify
6. Where do you prefer going for dental care?
Private dental office
Health centre/Community clinic
Hospital outpatient department
7. 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
8. Are you satisfied with the kind of dental care you received at the hands of your dentist?
Yes
No
9. Did you face any difficulty in choosing a good dentist?
None
Very few
Few
Many
10. How many times have you visited a dentist in last one year?
Never
Once
Twice
Thrice
More than 3 times
11. How would you rate the health of your teeth/gums?
Excellent
Very good
Good
Fair
Poor
12. 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
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