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Teeth Survey
Dear Sir or Madam, please take a few minutes of your time to complete the following questionnaire.
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1
How often do you brush your teeth?
Please select the frequency of brushing your teeth.
Once a day
Twice a day
Three times a day or more
2
Rate the health of your teeth
Please rate the current health condition of your teeth.
3
Do you use dental floss regularly?
Please provide your answer in the text box below.
4
Have you had any teeth extraction procedures in the past year?
Please select Yes or No.
Yes
No
5
Rate your satisfaction with your current dentist
Please rate your satisfaction level with your dentist.
6
How often do you visit the dentist for a check-up?
Please select the frequency of dental check-ups.
Every 6 months
Once a year
Only when there is a problem
7
How would you rate the cleanliness of your toothbrush?
Please rate the cleanliness of your toothbrush on a scale of 1 to 10.
8
What brand of toothpaste do you use?
Please write the brand of toothpaste you use.
9
Do you drink sugary beverages frequently?
Please select Yes or No.
Yes
No
10
Are you satisfied with the color of your teeth?
Please select Yes or No.
Yes
No
Submit