ID #: Dental Health Questionnaire- Gai Na Ban Samran

DEMOGRAPHICS

1.Age: 2.Sex: M0/ F1

3.Children: 00 11 22 33 4+4

Age of Children: ____1 ____ 2 ____ 3_____4

Education level: None 0 Some College4

Primary1 Bachelors and up5

Secondary2

Vocational3

Occupation: Farmer0

Government Worker1

Service Industry2

Vendor3

Health4

Other5

Specify:

What is your household’s average monthly income?0-5,0000____ 5,001-10,0001 ____ 10,001- 20,000 2____ 20,001- 40,000 3____ 40,001+4 ____

How do you pay for healthcare?30 Baht Scheme0____ SSS1____ CSMB2 ____ Supplemental/ Private3 _____Out of Pocket 4_____ Uninsured5 ____

ACCESS

How long does it take you to travel to the dentist?0-15 minutes0 ____ 16-30 minutes1 ____ 31-45 minutes2 ____ 46-60 minutes3 __1-1.5 hours4 _____ 1.6-2 hours5 _____ 2+ hours 6____

How do you get to the dentist?Motorcy0 ___ Car 1___ Bus 2____ Song Tow 3 _____ Tuk tuk 4 ____ Taxi 5_____Car Pool 6____ Walk7 ____ Other (specify)8: __________________

How do you pay for the dentist?

30 Baht scheme 0____ SSS1 ____ CSMB2 _____ Supplemental/ Private3 _______

Out of Pocket 4____ Uninsured5_____

How much did you pay out of pocket at your last dentist visit? (Baht)0-200 0_____ 201- 5001____ 501-7502 ____ 751-10003 ____ 1000+4 _____

How long do you wait to see the dentist from the time you get to the dental clinic?0-15 minutes0 ___ 16-30 minutes 1___ 31-45 minutes2 ____ 46-60 minutes3 ____1-1.5 hours 4_____ 1.6-2 hours 5 _____ 2+ hours6 ____

Have you been to the dentist? Yes0/ No1

How long has it been since you’ve been to the dentist?0-6 months0 _____ 6-12 months 1____ 1-2 years 2____ 3-5 years3 _____ 6+ 4_____

Why do you go to the dentist?Cavity0 _____ Check-up/ cleaning1 _____ Tooth pain2 _____ Dental Injury3 ____Infection/ disease4 _____ Other (specify)5: ___________________________

Where do you go to get dental care?Private clinic 0____ District Hospital 1___ HPH 2____ Regional Hospital 3 _____VHV4 _____ School5 _____ Mobile Clinic6 ______ Other7 (specify)______None8 _____

KNOWLEDGE

Have you ever received Dental Health education: Y0/N1

Where did you learn about Dental Health?Private clinic0 ___ District Hospital1 _____HPH2 ____ Regional Hospital 3_____VHV4 _____ School5 _____ Mobile Clinic6 ______ Family7 _____ Other (specify)8____________ None 9_____

How long should you brush your teeth?0-15 seconds0 _____ 16-30 seconds1 _____ 31-60 seconds2 ___ 1 minute3_____

How often should you floss? (times/day)00 ____ 11 ____ 22 _____ 3+ 3_____

Do you use products with fluoride? Y0/ N1

If so, what products?Toothpaste0 ____ Mouthwash1 ____ Water2_______ Fluoride supplement3 ___Other (specify)4: __________

If so, why?

What dental hygiene products do you use?Toothpaste0 _____ Toothbrush1 _____ Floss 2____ Tooth picks 3____ Mouthwash 4_____ Fluoride supplement5 ______ Other (specify)6: __________

What habits are bad for your teeth?Smoking0 ____ Foods high in sugar1 ______ Acidic foods2 _____ Salty foods3 _____ Drinks high in sugar 4_____ Acidic drinks5 _____ Other (specify)6 ______________________________________

How should you take care of your teeth?Brushing0 ____ Flossing1 ______ Using mouthwash2 ______ Preventative dental care 3____ Fluoride4 ______ Curative dental care5 _____ Moderating sugar and acid 6_____ Other (specify)7 ______

Are any dental services covered by your insurance? Y0/N1

If so, which services?Fillings0 _____ Cleanings1 ____ Oral Surgery2 _____ Root Canal3 ____Cosmetics (caps/ veneers)4 _____ Other (specify)5: ______________