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すべてのテンプレート
Healthcare & Clinical

Dental Screening & Oral Health Check-In Survey

Captures a patient's oral hygiene habits, symptoms, and dental visit history ahead of or following a screening, for dental practices, insurers, or public health programs. The AI follow-up interview digs into any reported pain or concern to surface details a checklist alone would miss, helping clinicians triage and prioritize care.

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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15問・約8分
Q01
メッセージ

Hi! Before your dental screening, we'd like to understand your oral health habits and any concerns you have. Your responses are completely confidential and anonymized. This takes about 8 minutes and helps your care team prepare for your visit.

Q02
選択式必須

When was your last dental visit (checkup, cleaning, or treatment)?

  • Within the last 6 months
  • 6-12 months ago
  • 1-2 years ago
  • More than 2 years ago
  • I've never been to a dentist
Q03
選択式必須

What is the main reason for this dental visit?

  • Routine checkup or cleaning
  • Specific pain or discomfort
  • A broken or chipped tooth
  • Follow-up on previous treatment
  • Cosmetic concern
Q04
マトリクス必須

In the last 3 months, how often have you experienced any of the following?

5行 × 4列
  • Tooth pain or sensitivity
  • Bleeding or swollen gums
  • Bad breath
  • Jaw pain or clicking
  • Difficulty chewing
列: Never · Rarely · Sometimes · Often
Q05
選択式必須

In the last week, how many times per day did you brush your teeth on average?

  • I didn't brush daily
  • Once a day
  • Twice a day
  • Three or more times a day
Q06
選択式必須

In the last week, how often did you floss or use an interdental cleaner?

  • Never
  • 1-2 times
  • 3-5 times
  • Every day
Q07
オピニオンスケール必須

Overall, how would you rate the current health of your teeth and gums?

スケール: 1 – 7
最小:Very poor最大:Excellent
Q08
評価スケール

How anxious or uncomfortable do you typically feel about dental visits?

範囲: 1 – 5
最小:Not at all anxious最大:Extremely anxious
Q09
AIインタビュー

If the respondent reported any pain, sensitivity, bleeding, or jaw discomfort, probe for specifics: where exactly it's located, how long it's been happening, what triggers it (cold, chewing, brushing), and whether it's getting worse. If they reported high dental anxiety, gently explore what specifically makes visits stressful (past experience, needles, cost, loss of control) so the care team can adjust the visit. If no symptoms or anxiety were reported, ask a light confirmation question about their current oral care routine instead.

Q10
選択式

What, if anything, makes it hard for you to get dental care when you need it?

  • Cost or lack of insurance
  • Fear or anxiety about dental visits
  • Difficulty getting time off work or school
  • Trouble finding a nearby provider
  • Long wait times for appointments
Q11
選択式

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

  • Yes
  • No
  • Not sure
Q12
メッセージ

Just a couple of quick background questions to finish up.

Q13
選択式

What is your age group?

  • Under 18
  • 18-24
  • 25-34
  • 35-44
  • 45-54
  • 55-64
  • 65 or older
  • Prefer not to say
Q14
選択式

What is your gender?

  • Woman
  • Man
  • Non-binary
  • Prefer to self-describe
  • Prefer not to say
Q15
メッセージ

Thank you for sharing this with us! Your responses will be reviewed by your care team ahead of your screening so they can focus on what matters most to you.

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 a static checklist with an AI follow-up interview that automatically digs deeper into any reported pain, sensitivity, bleeding, or jaw discomfort, surfacing detail a fixed form would miss.
  • Combines structured habit-tracking (brushing/flossing frequency, last visit, symptom matrix) with opinion-scale and rating questions on perceived oral health and dental anxiety, giving clinicians both quantitative and qualitative signal.
  • Includes a barriers-to-care question and insurance/benefit status alongside demographics, helping practices and public health programs triage and prioritize outreach, not just log symptoms.
  • Closes with a clear message that responses are reviewed by care staff, and every response is automatically quality-scored with an auto-generated report for the clinical team — no manual chart review needed.

SurveySparrow

Dental Screening Form Template

A ready-to-use static dental screening form covering standard intake and symptom questions. It's built for quick deployment on SurveySparrow's conversational form platform but relies entirely on fixed question logic. Good for basic intake, but not designed to probe deeper into open-ended symptom reports.

優れている点

  • Fielding-ready template, no build-from-scratch effort needed
  • Conversational form UI likely improves completion rates over a paper form
  • Positioned specifically for healthcare/dental use cases

物足りない点

  • No adaptive follow-up on reported pain or symptoms — respondents get the same fixed questions regardless of answers
  • No voice AI interview option or guided screen-share task capability
  • No visible automated quality scoring or auto-generated clinician-facing report

Typeform

Dental Screening Form

Typeform offers a polished, conversational-style dental screening template focused on visual design and one-question-at-a-time flow. It's a solid static form for collecting habit and symptom data but does not adapt its questioning based on responses. Best suited to simple intake rather than clinical triage.

優れている点

  • Clean, mobile-friendly conversational form design
  • Easy to customize branding and question wording
  • Fielding-ready template usable immediately

物足りない点

  • Purely static logic — cannot dynamically interview a respondent who reports pain or discomfort
  • No option for voice-based interviewing or screen-share guided tasks
  • No built-in per-response quality scoring or auto-generated summary report for clinical review

よくあるご質問

「Dental Screening & Oral Health Check-In 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15問含まれており、最初の設問は次のとおりです：「Hi! Before your dental screening, we'd like to understand your oral health habits and any concerns you have. Your respon…」・「When was your last dental visit (checkup, cleaning, or treatment)?」・「What is the main reason for this 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、15問を約8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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