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Hi there, please fill out and submit this form. This form has been funded by CDPH under contract 22-10208.
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1
By clicking the "agree statement" below, I indicate that I would like to be a part of this project by consenting to taking this survey
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This field is required.
Yes, I agree to participate in this survey.
No, I do not agree to participate in this survey.
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2
How would you evaluate the health of your teeth, gums, and mouth?
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Excellent, I rarely have issues.
Good, any issues I had were treated.
Fair, I have issues, but I can get treatment.
Poor, I consistently have many issues but do not get treatment.
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3
How important is the health of your teeth, gums, and mouth to you?
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Extremely important.
Very important.
Somewhat important.
Not so important.
Not at all important.
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4
How often do you brush your teeth?
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Three times a day or more
Twice a day
Once a day
A few times a week
Rarely
Never
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5
How often do you floss your teeth?
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Three times a day or more
Twice a day
Once a day
A few times a week
Rarely
Never
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6
Do you have dental insurance?
*
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Yes
No
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7
What type of dental insurance do you have?
*
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Through my employer or a family member's employer coverage
Through Denti-Cal (Medi-Cal Dental Program)
Covered California
Through the Department of Veterans Affairs
I cannot afford dental insurance
I do not want dental insurance
Through an insurer not listed here
Unknown/Unsure
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8
When was your last visit to the dentist?
*
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Within the last six months
Within the last year
Within the last two years
Within the last five years
Never
More than five years ago
Other
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9
What was the reason for your last dental visit? (Check all that apply)
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Six-month cleaning
Annual check-up
Treatment for an issue
Follow-up treatment
Other
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10
How do you feel about the care you received at your last dental visit?
*
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Excellent, I felt respected and approved of the treatment that was done.
Good, I approved of the treatment that was done.
Fair, I felt okay about my visit.
Poor, I was unsure of why or what treatment was provided.
Horrible, I did not feel respected and was unsure of why they did the treatment.
I have never been to the dentist.
Other
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11
How far is your dental home (dentist office) from your home?
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Ten minutes or less
Thirty minutes or less
Within an hour
Over an hour
I do not have a dental home
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12
What zip code or city is your dental home (dentist office) located?
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13
During the last year, has there been a time when you needed dental care, but could not get it?
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Yes, I did not receive the care that I needed.
No, I received the care that I needed.
No, I did not need care.
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14
What is your experience in trying to get dental care? Select all that apply
*
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It was great.
It was too expensive.
I do not know where to go to get dental care.
I cannot find a dentist that is taking new patients.
The wait time for my appointment was too long.
The appointment was cancelled by the dentist office.
I missed the appointment.
I do not have transportation to the dentist.
I do not like going to the dentist.
No one at the dentist office speaks my language.
Other
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15
If you do not like going to the dentist, please indicate why. (Select
all
that apply)
*
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I do not mind going to the dentist.
Fear or nervousness.
Hard to schedule with my work/school.
Bad past experience.
Hard to schedule appointments with the dental office.
I cannot afford it.
Transportation issues.
No reason to go to dentist office, my teeth are fine.
Language barrier.
I do not know where to go.
The waiting time at the dental office.
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16
During the past year have you required emergency care for a dental related issue
*
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Yes
No
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17
If you selected yes to the question above, where did you seek emergency dental care?
Local emergency department
Out-of-county emergency department
Local dental provider
Out-of-county dental provider
Did not seek care
Not Applicable
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18
Do you use tobacco products (including cigarillos, cigars, cigaritta, pipe tobacco, chewing tobacco, vape pen, hookah, e-cigarettes or Juul)?
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Yes, daily
Yes, sometimes
I used to, but I quit
I tried it a few times
Never
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19
Does your medical doctor (primary care physician) ever ask you about your dental health?
*
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Yes
No
I do not have a medical doctor/primary care physician.
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20
Have you had any of the following in the past year? (Select all that apply)
*
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Bleeding gums
Swelling/abscess
Loose teeth
Cavities
Crown
None
Root Canal
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21
Have you ever had an adult tooth pulled (not including your wisdom teeth)?
*
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Yes
No
Unsure
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22
How many of your adult teeth have been removed or lost? (Do not include wisdom teeth)
*
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None
1-5
6 or more
All
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23
What is your experience in keeping your teeth, gums, and mouth healthy? (Select all that apply)
*
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I do well in keeping my teeth, gums, and mouth healthy.
Going to the dentist is too expensive.
Toothbrushes, toothpaste, and floss are too expensive.
I am too busy.
I cannot take time off of work for routine care.
I do not have someone to watch my child(ren) to seek care.
I do not have a way to get to the dentist.
My housing issues have affected the health of my teeth, gums, and (or) mouth.
I have other medical needs that are more important.
Other
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24
There is a connection between gum disease and heart disease.
*
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True
False
Unsure
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25
There is a connection between gum disease and diabetes.
*
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True
False
Unsure
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26
Baby teeth are not that important because they are going to fall out anyway.
*
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True
False
Unsure
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27
Fluoride strengthens (or helps to protect) teeth and helps prevent cavities.
*
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True
False
Unsure
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28
Fluoride-treated water is not good for your health.
*
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True
False
Unsure
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29
A woman should not have dental treatment during pregnancy.
*
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True
False
Unsure
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30
Xylitol is an alternative anti-cavity mineral effective in preventing tooth decay.
*
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True
False
Unsure
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31
Children should have their first dentist visit by:
*
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Age 1 or when their first tooth comes in
Age 3
When the child starts school
Unsure
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32
Where do you get your drinking water?
*
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Well water
County/City Water
Bottled water
Unsure
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33
Is the tap water in your home fluoridated?
*
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Yes
No
Unsure
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34
How do you feel about fluoride (select all that apply):
*
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I buy toothpaste with fluoride.
I drink tap water with fluoride.
I get fluoride treatments at the dentist.
I use fluoride tablets or drops.
I am unsure about my fluoide intake.
I am unsure what fluoride is.
I avoid fluoride.
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35
Do you have a child(ren) between the ages of 0 (infant) and 17 years old
Yes
No
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36
Has your child or children ever had dental sealants applied? (Select all that apply.)
*
This field is required.
Yes
No
I am unsure what a dental sealant is.
I am unsure if my child(ren) have had this done.
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37
Has your child or children ever had fluoride varnish placed on their teeth? (Select all that apply.)
*
This field is required.
Yes
No
I am unsure what fluoride varnish is.
I am unsure if my child(ren) have had this done.
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38
Does your child or children have any dental problems right now?
*
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Yes
No
Unsure
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39
Does your child's or children's medical doctor (primary care physician) ever ask about dental care or look at the child's teeth during a well-child exam?
*
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Yes
No
Unsure
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40
How many times a day does your child or children drink sugar-sweetened beverages (like soda, sports drinks, juice, or punch)?
*
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Rarely
1-2 times a week
3-4 times a week
Every day
Never
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41
What zip code or city do you reside in?
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42
What is your age group?
*
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18-23 Years
24-35 Years
36-45 Years
46-64 Years
65+ Years
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43
What is your race/ethnicity?
*
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American Indian or Alaskan Native
African American or Black
Hispanic/Latino
Asian American or Asian
Pacific Islander
White or Caucasian
Two or more ethnicities
Prefer not to answer
Other
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44
Gender, how do you identify:
*
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Male
Female
Non-binary
Prefer not to answer
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45
Are you currently a part of any of these programs? (Select all that apply)
*
This field is required.
Medi-Cal
Medi-Care
WIC
SNAP/CalFresh Food
Disability/SSI
Unemployment benefits
Not applicable
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