Dental care monitoring questionnaire template

Dear Sir / Madam,

thank you for visiting us. By filling out this 5-10 minute survey, you will help us obtain the very best results.

1. Do you presently have a dentist that you visit on a regular basis?

  • Answer #1
  • Answer #2

2. How did you find your dentist?

  • Referral by friend / family
  • Referral by another dentist
  • Referral by school
  • Advertisement
  • Can't remember

3. The most common reason for not going to the dentist is:

  • I do go for regular check-ups
  • The cost of care
  • I don't need to go very often
  • I forget to go
  • I don't like dentists
  • There is nothing wrong with my teeth
  • I am scared!

4. Since when have you made regular visits to the current dentist?

  • < 1 year
  • 1-2 years
  • 2-3 years
  • 3-4 years
  • 4+ years

5. Do members of your household go to:

  • One dentist
  • More than one dentist

6. How often do you go to the dentist for checkups?

  • Every 6 months
  • At least once a year
  • At least every 2 years
  • At least once every 3-4 years
  • It depends, I go when I have trouble with my teeth

7. Would you like your dentist to notify you when it is time for a check-up?

  • Yes
  • No
  • Not sure

8. How would you prefer to receive this notice?

  • Phone call
  • SMS
  • E-mail

9. What do you like best about your personal dentist?


10. What would you suggest that might make a visit to your dentist more pleasurable?


Use template — it’s free

Dental Care Survey

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Become a top dental institution and patients will find you. The questionnaire template for dental care will give you objective information on the level of your care.

Use template — it’s free

The survey sample is ideal for

  • dentists,
  • workers in the field of dentistry.

Background, staff, services, facilities or availability. To this extent, the level of medical facilities is usually assessed. Get an idea of what current patients think of your office or clinic. At the same time, you can read from the answers how consistently they take care of their teeth and, based on the examination, you will design a plan of preventive examinations. Have them fill out the questionnaire for dental care monitoring and meet their expectations, which will provide you with positive recommendations and bring in new potential patients.

The questionnaire template can be fully edited. Survio will process your answers into well-arranged tables and graphs.

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