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Lidocaine Oral Thin Film Questionnaire For Patients
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* Indicates required question
1. Indicate how much film residue left in your mouth?
*
None
0
1
2
3
4
5
6
7
8
9
10
Large Amount
2. What was the dental procedure that required you to use the oral thin film?
*
Your answer
3. Do you normally get dental freezing for this procedure?
*
Yes
No
4. Was this a more comfortable way of getting the freezing?
*
Yes
No
5. How long did the film take to dissolve?
*
<10s
30s
1 min
1.5 min
Greater
6. How does it taste?
*
Great
Good
Okay
Bad
No taste
7. How long did it take for the freezing effect to set in?
*
<1 min
1 min
2 min
3 min
4 min
5 min
8. How long did the freezing last without local injectable anesthetic?
*
5 min
10 min
15 min
20 min
More than 20 min
9. Where was the film placed?
*
Choose
Tongue
Cheek
Palate
Gums (Lower)
Gums (Upper)
Lip
10. Where did you feel the effect the most?
Rank from 1- 10 (1- No Effect, 10 - Heavy Effect)
*
1
2
3
4
5
6
7
8
9
10
Tongue
Cheek
Palate
Gums (Lower)
Gums (Upper)
Lip
1
2
3
4
5
6
7
8
9
10
Tongue
Cheek
Palate
Gums (Lower)
Gums (Upper)
Lip
11. Was additional freezing needed?
*
Yes
No
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