12 Oral Health

ID NUMBER:

FORM CODE: OHE VERSION: A 07/09/07

Contact Occasion

SEQ #

OMB#: 0925-XXXX

Exp. XX/XXXX

Public reporting burden for this collection of information is estimated to average 05 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-XXXX). Do not return the completed form to this address.

H

OMB#: 0925-XXXX

Exp. XX/XXXX

CHS/SOL Oral Health Questionnaire

ID NUMBER:

FORM CODE: OHE VERSION: A 7/09/07

Contact Occasion

SEQ #

Acrostic:

Administrative Information

0a. Completion Date: // 0b. Staff ID:

Month Day Year

Instructions: For each question, mark the appropriate response. Unless instructed, mark ONLY one response.

                                                

A. Natural Teeth

1. Do you have any of your natural teeth?

No 0  GO TO QUESTION 10

Yes 1

2. How often do you limit the kinds or amounts of food you eat because of problems with your teeth? Would you say:

Always 1

Very often 2

Often 3

Sometimes 4

Seldom 5

Never 6

Refused 7

Don’t know 9

3. In the past 12 months have you had or do you currently have:

No Yes

a. Pain in a tooth or teeth 0 1

b. Bleeding gums 0 1

c. Pain in your face 0 1

d. Pain in your jaw joint 0 1

e. Sores in your mouth 0 1

f. Difficulty chewing 0 1

g. Difficulty tasting 0 1

h. Difficulty swallowing 0 1

i. Bad breath 0 1

j. Bad taste in mouth 0 1

k. Dry mouth when you eat 0 1

l. Dry mouth when you sleep 0 1

m. Other (non toothache) pain in your mouth 0 1

4. Do you think or believe that you are currently in need of dental treatment?

No 0  GO TO QUESTION 6

Yes 1

5. What type of dental care do you need now? (Mark all that apply)

a. Cleaning or checkup

b. Teeth filled or replaced (for example,

fillings, crowns, and/or bridges)

c. Teeth pulled

d. Gum treatment

e. New or replace denture(s)

f. Denture repaired

g. Relief of pain

h. Work to improve appearance (for example,

braces, bonding, or whitening)

i. Other

If other, please specify:_______________

j. Don’t know

6. About how long has it been since you last visited a dentist? Include all types of dentists, such as, orthodontists, oral surgeons, and all other dental specialists, as well as dental hygienists. (Mark only one)

6 months or less 1  GO TO QUESTION 8

More than 6 months, but not more than 1 year ago 2  GO TO QUESTION 8

More than 1 year, but not more than 2 years ago 3

More than 2 years ago, but not more than 3 years ago 4

More than 3 years, but not more than 5 years ago 5

More than 5 years ago 6

Never have been 7

Refused 8

Don’t know 9

7. What are the reasons you have not visited the dentist in over 12 months/never gone to the dentist? (Mark all that apply)

a. Afraid

b. Nervous

c. Needles

d. Cost

e. Don’t know dentist

f. Dentist too far

g. Can’t find a dentist who speaks Spanish

h. Can’t get there

i. No problems

j. No teeth

k. Not important

l. Didn’t think of it

m. Other

If other, please specify: ___________

n. Don’t know

8. Have you ever had a test {/exam} for oral or mouth cancer in which the doctor or dentist, pulls on your tongue, sometimes with gauze wrapped around it, and feels under the tongue and inside the cheeks?

I think so 0

Yes 1

No 2  GO TO QUESTION 18

Don’t know, not sure 9  GO TO QUESTION 18

9. When did you have your most recent oral or mouth cancer exam?

Within past year 1

Between 1 and 3 years ago 2

Over 3 years ago 3

GO TO SECTION C, QUESTION 18

B. Edentulous Questions

10. How often do you limit the kinds or amounts of food you eat because of problems with your dentures? Would you say:

Always 1

Very often 2

Often 3

Sometimes 4

Seldom 5

Never 6

Refused 7

Don’t know 9

11. In the past 12 months have you had or do you currently have:

No Yes

a. Bleeding gums 0 1

b. Pain in your face 0 1

c. Pain in your jaw joint 0 1

d. Sores in your mouth 0 1

e. Difficulty chewing 0 1

f. Difficulty tasting 0 1

g. Difficulty swallowing 0 1

h. Bad breath 0 1

i. Bad taste in mouth 0 1

j. Dry mouth when you eat 0 1

k. Dry mouth when you sleep 0 1

l. Other (non toothache) pain in your mouth 0 1

12. Do you think or believe that you are currently in need of dental treatment?

No 0  GO TO QUESTION 14

Yes 1

13. What type of dental care do you need now? (Mark all that apply)

a. Gum treatment

b. New or replace denture(s)

c. Denture repaired

d. Relief of pain

e. Other If other, please specify:___________ f. Don’t know

14. About how long has it been since you last visited a dentist? Include all types of dentists. (Mark only one)

6 months or less 1  GO TO QUESTION 16

More than 6 months, but not more than 1 year ago 2  GO TO QUESTION 16

More than 1 year, but not more than 2 years ago 3

More than 2 years, but not more than 3 years ago 4

More than 3 years, but not more than 5 years ago 5

More than 5 years ago 6

Never have been 7

Refused 8

Don’t know 9

15. What are the reasons you have not visited the dentist in over 12 months/never gone to the dentist? (Mark all that apply)

a. Afraid

b. Nervous

c. Needles

d. Cost

e. Don’t know dentist

f. Dentist too far

g. Can’t find a dentist who speaks Spanish

h. Can’t get there

i. No problems

j. No teeth

k. Not important

l. Didn’t think of it

m. Other

If other, please specify: ___________

n. Don’t know

16. Have you ever had a test {/exam} for oral or mouth cancer in which the doctor or dentist, pulls on your tongue, sometimes with gauze wrapped around it, and feels under the tongue and inside the cheeks?

I think so 1

Yes 2

No 3  GO TO QUESTION 18

Don’t know, not sure 9  GO TO QUESTION 18

17. When did you have your most recent oral or mouth cancer exam?

Within past year 1

Between 1 and 3 years ago 2

Over 3 years ago 3

C. Problem with Teeth, Mouth, or Dentures

18. During the past month have you had difficulty doing your usual jobs or attending school because of problems with your teeth, mouth or dentures?

Always 1

Very often 2

Often 3

Sometimes 4

Seldom 5

Never 6

Refused 7

Don’t know 9

Oral Health Form (OHE) Page 0 of 4