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Healthcare & Clinical

Dental Health History and Care Habits Survey

Captures a respondent's dental visit history, oral hygiene habits, past procedures, and comfort level with dental care, for use by clinics, insurers, or researchers studying access and prevention. An AI follow-up interview digs into the real reasons behind dental anxiety or delayed care, going beyond a checkbox answer.

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設問の例

テンプレートの内容をプレビューできます。すべての設問は公開前に自由に編集できます。

全13問・約7分
Q01
メッセージ

Thanks for taking a few minutes to share your dental health history. Your answers help us understand how people care for their teeth and what gets in the way of visiting the dentist. Your responses are completely confidential and anonymized. This should take about 5 minutes, and there are no wrong answers.

Q02
選択式必須

When was your last dental check-up or cleaning?

  • Within the last 6 months
  • 6-12 months ago
  • 1-2 years ago
  • More than 2 years ago
  • I've never had one
Q03
選択式必須

What was the main reason for your most recent dental visit?

  • Routine cleaning or check-up
  • Pain or discomfort
  • A cosmetic concern
  • Emergency (injury or broken tooth)
  • Follow-up on prior treatment
Q04
マトリクス必須

In a typical week, how often do you do each of the following?

3行 × 5列
  • Brushing your teeth
  • Flossing
  • Using mouthwash
列: Never · A few times a week · Once a day · Twice a day · More than twice a day
Q05
オピニオンスケール必須

How would you rate the current health of your teeth and gums?

スケール: 1 – 10
最小:Poor最大:Excellent
Q06
選択式

Which of the following dental procedures have you had in the past? Select all that apply.

  • Filling
  • Root canal
  • Tooth extraction
  • Crown or bridge
  • Braces or other orthodontics
  • Dental implant
  • Professional teeth whitening
Q07
オピニオンスケール必須

How anxious or nervous do you feel about visiting the dentist?

スケール: 1 – 7
最小:Not anxious at all最大:Extremely anxious
Q08
選択式必須

In the last 12 months, has cost ever kept you from getting dental care you needed?

  • Yes
  • No
  • Not sure
Q09
選択式

Do you currently have dental insurance or a dental benefit plan?

  • Yes
  • No
  • Not sure
  • Prefer not to say
Q10
AIインタビュー

Explore the specific source of the respondent's dental anxiety or hesitation—whether it stems from pain, a past bad experience, sounds or smells, cost, or loss of control—and how that anxiety has actually changed their behavior, such as delaying a visit or avoiding a specific procedure. If they reported low anxiety, ask what makes their visits comfortable so we can identify best practices to share with providers. If they flagged cost as a barrier, probe what specific expense or insurance gap caused them to skip care and what it would take for them to return.

Q11
選択式

Which age range do you fall into?

  • Under 18
  • 18-24
  • 25-34
  • 35-44
  • 45-54
  • 55-64
  • 65 or older
  • Prefer not to say
Q12
選択式

What is your gender?

  • Woman
  • Man
  • Non-binary
  • Prefer not to say
Q13
メッセージ

That's everything, thank you! Your responses will be combined with others to help improve dental care access and reduce the barriers that keep people from getting the treatment they need.

含まれる機能

  • AIによる深掘り

    自由回答に合わせてAIが追加で質問し、固定のフォームでは拾えない具体的な内容を引き出します。

  • 注意確認設問

    急いだ回答や質の低い回答者を除外する仕組みを標準で備えています。

  • AIが作成する設問文

    文言、設問の順序、条件分岐をAIが調査の目的に合わせて作成します。

  • 自動レポート

    回答が集まると、テーマ、引用、わかりやすい要約が自動で作成されます。

他ツールとの比較

ほかのアンケートツールで最も近いテンプレートを調べました。それぞれの優れている点と、このテンプレートがさらに踏み込んでいる点をまとめています。

このテンプレートを選ぶ理由

  • Goes beyond checkbox history questions with an AI follow-up interview that explores the real reasons behind dental anxiety or delayed care
  • Combines structured questions (visit timing, procedures had, weekly hygiene habits via a matrix question, insurance and cost-barrier questions) with open-ended AI probing in one flow
  • Captures self-rated oral health and anxiety on opinion scales, then lets the AI interview dig into the 'why' behind those ratings rather than stopping at a number
  • Includes demographic questions (age range, gender) so clinics, insurers, or researchers can segment access and prevention patterns

SurveySparrow

Dental Health History Questionnaire

A ready-to-field dental health history template covering visit history and habits, built on SurveySparrow's conversational-style form format. It's designed for quick self-serve deployment by dental practices rather than deep behavioral research. No indication of adaptive follow-up questioning beyond its fixed script.

優れている点

  • Fielding-ready template, no build required
  • Conversational chat-style UI that can feel more personal than a standard form
  • Likely easy to embed on a dental practice website or patient portal

物足りない点

  • Static question set with no adaptive AI follow-up to probe reasons behind anxiety or delayed care
  • No automated per-response quality scoring
  • No voice AI interview option

Jotform

Dental Health History Form Template

A standard fillable form template for capturing dental history, likely aimed at intake/onboarding at a dental office rather than research. Strong for form-building flexibility and integrations but is a static questionnaire, not an interview instrument. Good for paperwork replacement, less suited to studying the 'why' behind patient behavior.

優れている点

  • Highly customizable form builder with drag-and-drop fields
  • Broad integration ecosystem (payments, e-signature, storage)
  • Familiar, easy-to-complete form format for patients

物足りない点

  • No adaptive AI follow-up interview or voice interview option
  • No automated quality scoring of responses
  • Not designed to surface underlying reasons for anxiety or delayed care, only checkbox/text answers

Typeform

Dental Health History Form Template

A polished, one-question-at-a-time dental history template with Typeform's signature conversational design. It's well-suited to patient intake and general data collection but functions as a fixed-path form, not a research interview tool. No mention of AI-driven probing or scoring of response quality.

優れている点

  • Clean, engaging one-question-at-a-time UI known for high completion rates
  • Easy to theme/brand for a clinic or organization
  • Simple logic-based branching between fixed questions

物足りない点

  • No AI follow-up interview to explore root causes of anxiety or care avoidance
  • No voice AI interview option
  • No automated per-response quality scoring or auto-generated analytical reports

よくあるご質問

「Dental Health History and Care Habits Survey」テンプレートにはどのような設問が含まれていますか？

すぐに使える設問が13問含まれており、最初の設問は次のとおりです：「Thanks for taking a few minutes to share your dental health history. Your answers help us understand how people care for…」・「When was your last dental check-up or cleaning?」・「What was the main reason for your most recent dental visit?」。すべての設問は上でプレビューでき、自由に編集できます。

このアンケートの回答にはどのくらい時間がかかりますか？

回答者は通常、13問を約7分で回答し終えます。

テンプレートは編集できますか？

はい。公開前であれば、すべての設問、選択肢、順序を編集できます。設問の追加や削除のほか、調査の目的に合わせた作り直しをAIエディターに依頼することもできます。

このテンプレートは無料で使えますか？

はい。エディターで開けば、すぐに編集を始められます。お試しにアカウントは不要で、無料プランでアンケートを公開できます。

公開の準備はできましたか？

このテンプレートをエディターで開いてみてください。最初の回答者が目にする前に、すべてを自由に変更できます。

このテンプレートを使う無料で始める

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