Virtual Special Smiles Self Assessment Program
Special Olympics Kansas
Thank you for participating in the Virtual Special Smiles Self Assessment Program.
This is a survey where you will answer each question by checking the box or filling in information.
There are no right or wrong answers.
There will be a Special Smiles- Health Interactive Session scheduled by your Special Olympics Program.  
Sign in to Google to save your progress. Learn more
Name *
How old are you? Please select your age (age range) *
Which Category are you? (Check all that apply) *
Required
Do you have a Local Dentist or Oral Health Professional? *
How often do you visit the Dentist/Oral Health Professional? *
Have you ever had trouble finding oral health care or finding a dentist? *
How often do you clean your mouth? ( Brush, floss, Wipe or other ways you clean your teeth, gums and mouth) *
Do you have teeth? *
Do you wear dentures, partial dentures, "plates" or wear braces (orthodontics)? *
Have you ever had a filling or sealant? (silver, white, gold) (as child or adult) *
Which statement is true? *
Take a 5-minute break
Feel free to take a 5-minute break or keep going!
Do you take daily medications? *
Do you take medicine for ANY of the following? Blood pressure, seizures, allergies, constipation, mood, asthma? *
Is your saliva (spit) more like? *
Do you drink water more than 1 liter or 5 glasses a day? *
How often does food get stuck between your teeth? *
Do you play a sport that has contact with other players? Like basketball, wrestling, soccer and others… *
If you play a sport that has contact with other players, do you wear a mouth guard? *
Activity: When you look in a mirror and open your mouth, which picture looks like yours? Do you see the back of your mouth? *
Do you experience any of the following? (check all that apply)
Take a 5-Minute Break
Feel free to take a 5-minute break or keep going!
Activity: Is it easy to put your lips together and breathe thru each nostril? (put your lips together, close off one nostril gently and breathe, then the other nostril) *
Do you want to learn how to have and keep a healthy smile? *
Do you experience pain in your mouth, especially during or after eating? *
Do you have pain inside your mouth? Tell me more. (check all that apply) *
Required
Do ANY of your teeth feel sensitive to cold, hot or sweet foods or liquid? (check all that apply) *
Required
Do you have difficulty chewing *
Look at your front top teeth in the mirror, do you have any chips or broken edges of your teeth? *
Do you see signs of bleeding from your mouth when you Brush, Floss, or Rinse”Is it reddish/ pink in the sink? *
Did you learn something new today? *
If you could have a One to One Zoom (virtual) consult to ask a Dentist or Oral Care Provider a question, would you be interested? *
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