Patient Questionnaire
For dentists that predominantly provide care under a
capitation arrangement
.
1. Based on your recent appointments, please select the extent to which you agree with the following statement: "Because of the advice I have received, I feel more able to look after my teeth, gums and mouth".
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
2. Please explain why you feel this way.
3. How would you like to receive advice about how to keep your teeth, gums and mouth healthy? (you can select more than one, if you select other, please give detail)
Information sent to me before an appointment
Information displayed in the waiting room
Discussion with me by the dental team
Information sent to me after an appointment
Other
4. If more information was shared with you before or after your dental appointment, what format would you like this to be in? (if you select other, please give detail)
Letter
Email
Text
Phone call
Website / online resource
Other
5. Who gave you advice on how to care for your teeth, gums and mouth during your recent visits? (you can select more than one, if you select other, please give detail)
Dentist
Dental Hygienist or Dental Therapist
Dental Nurse
Not sure
Other
6. At your recent visits you may have discussed one or more of the following topics. Which of these topics did you find most useful to discuss? (select all that apply)
Toothbrushing and/or interdental cleaning (cleaning between your teeth)
Denture cleaning (if applicable)
Diet (things you eat and drink)
Reducing or quitting smoking
Reducing alcohol intake
Medical considerations (such as medicines, diabetes, pregnancy etc)
Reducing your risk of developing oral cancer
Back
Next
Did you receive any of the following at your recent visits? (you can select more than one, if you select other, please give detail)
Fluoride varnish application
Scale and polish
A toothbrushing/interdental cleaning demonstration
Other
Which of the following do you think is the most effective in helping prevent dental disease? (select all that apply)
The discussion and advice given to me by the dental team
Fluoride varnish application
Scale and polish
A toothbrushing/interdental (in between your teeth) cleaning demonstration
Based on your recent visits, how satisfied are you with the care and advice on keeping your teeth, gums and mouth healthy?
Very satisfied
Satisfied
Neither satisfied nor dissatisfied
Dissatisfied
Very dissatisfied
Is there anything else you'd like to tell us about your experience of receiving advice on caring for your teeth, gums and mouth to keep them healthy?
Thank you for your time and participation.
Preview PDF
Submit
Should be Empty: