Individual Data Collection
Oral Health Survey

Please answer the following questions to the best of your ability.

Age Range: *
Gender: *
Race: *
Ethnicity: *
Insurance Status: *
Length of time since last dental visit: *
Length of time since last dental visit: *
Untreated Decay (presence of at least one dental cavity in primary (baby) or permanent teeth): *
Previously Treated Decay (e.g. restoration, filling, crown, or fixed prosthetics): *
Early Childhood Caries (ECC): *
Existing Sealants on First Permanent Molar Teeth: *
Sealant Placement *
Denture Use (presence of either partial or full removable denture): *
During last dental visit were you diagnosed needing periodontal care (periodontal therapy includes scaling and root planing or surgery): *
Treatment Urgency: *
Fluoride Varnish application during last dental visit: *
During your last dental visit did you receive Prophylaxis (Prophy=teeth cleaning): *
Oral Health Instruction (OHI): *
During last dental visit did you receive restorative care or dental surgery: *
Other Dental Care: *
During the past 12 months, how many times have you gone to a hospital emergency room for dental problem? Do not count visits for injury or trauma. *

BSS indicator descriptions:

PK = preschool children, SA = school age children, AD = adults

Untreated decay (PK, SA, AD): presence of active caries in primary and permanent dentition

Treated decay (PK, SA, AD): previously treated decay (e.g. restoration) in primary and permanent dentition. This category also includes fixed prosthetics, including crowns and restored implants.

Existing sealants (SA): sealants (either full or partial) that are present on permanent molar teeth. Exclude sealants on non-molar permanent teeth or on the primary dentition

Early childhood caries (PK): presence of caries on the six maxillary primary anterior teeth. For the BSS, mandibular anterior teeth are not included

Denture use (AD): presence of either partial or full removable dentures

Number of natural teeth upper arch (AD): the number of natural teeth present in the upper arch

Number of natural teeth lower arch (AD): the number of natural teeth present in the lower arch

Need for Periodontal Care (AD): patient needs periodontal treatment (dental prophylaxis or other periodontal therapy) before the next dental visit

Treatment Urgency (PK, SA, AD):

No obvious problem: there are no visible dental problems, routine care recommended

Early treatment: a dental problem is present and should be addressed within the next six months

Urgent treatment: pain or infection is present and the dental problem needs to be addressed immediately

Other Dental Care: any other dental service not included in the specific service responses. “Other Dental Care” includes services that you believe are important to disseminate, but are not routinely included in ROHDEO (e.g. case management).

Powered byFormsiteReport abuse