JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Oral Health Survey
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Would you be willing to share your story regarding access to dental care to a member of the Utah Health Policy project to help in the advocacy of better oral health access in Utah? If so, please provide your phone number and email address.
*
Your answer
What kind of DENTAL insurance do you have?
None
Through my job
Through a family member
Medicaid
Medicare advantage
ACA/Obamacare/Individual Market
Other:
Clear selection
Do you face barriers accessing dental care? (please check all that apply)
Can’t get a dental appointment when you need it
Can’t afford dental care
Don’t have transportation to dental appointments
Dental provider is not handicapped accessible
Fearfulness of dental visit
Other:
How would you describe the condition of your teeth or dentures?
Your answer
How long has it been since you last visited a dentist or a dental clinic for any reason?
Less than 12 months ago
Between 1-2 years ago
Between 2-5 years ago
More than 5 years ago
Never
Do Not Remember
Clear selection
What was the reason for your last dental visit?
Your answer
Where do you currently get your dental care?
Private dental office
Hospital emergency room
Public dental clinic
I do not get dental care.
Clear selection
Is there anything else you'd like to share?
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
