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Oral Health Habits & Dental Care Experience Survey

Measures everyday brushing and flossing habits, common symptoms like gum bleeding or sensitivity, satisfaction with dental visits, and the real barriers keeping people from care. Built for dental practices, oral care brands, and public health researchers. An AI follow-up interview digs into the specific symptom or barrier each respondent flagged, uncovering the actual reasons behind it instead of a generic checkbox.

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Sample questions

A preview of what’s in the template. Every question is editable before you launch.

14 questions · ~7 min
Q01
Message

Hi! We're gathering honest input on everyday oral health habits and dental care experiences. There are no right answers — this takes about 8 minutes.

Q02
Multiple ChoiceRequired

In the last 7 days, how often did you brush your teeth?

  • Twice a day or more
  • Once a day
  • A few times this week
  • Once this week or less
Q03
Multiple ChoiceRequired

In the last 7 days, how often did you floss or use an interdental brush?

  • Every day
  • A few times
  • Once
  • Not at all
Q04
Multiple ChoiceRequired

How long has it been since your last dental checkup or cleaning?

  • Less than 6 months ago
  • 6-12 months ago
  • 1-2 years ago
  • More than 2 years ago
  • I've never been to a dentist
Q05
MatrixRequired

In the past 3 months, how often have you experienced each of the following?

4 rows × 5 columns
  • Bleeding or sore gums
  • Tooth or gum sensitivity to hot/cold/sweet
  • Bad breath you noticed yourself
  • Tooth, jaw, or mouth pain
Columns: Never · Rarely (a few times) · Sometimes (monthly) · Often (weekly) · Almost every day
Q06
Opinion ScaleRequired

Overall, how satisfied are you with the current health of your teeth and gums?

Scale: 1 – 7
Min:Very dissatisfiedMax:Very satisfied
Q07
Rating Scale

Thinking about your most recent dental visit, how would you rate the overall experience?

Range: 1 – 5
Min:Very poorMax:Excellent
Q08
Multiple ChoiceRequired

What, if anything, keeps you from seeing a dentist as often as you think you should? Select all that apply.

  • Cost of treatment
  • Lack of dental insurance
  • Fear or anxiety about dental visits
  • Difficulty finding time
  • Trouble finding a dentist I trust
  • Bad past experience
Q09
AI Interview

Probe into the respondent's most frequent or severe symptom from the earlier list (e.g., bleeding gums, sensitivity, pain) — ask when it started, whether it has changed recently, and what they've tried, if anything. Then connect it to their stated barriers to dental visits: understand whether cost, fear, time, or trust is the real blocker, and what would actually get them into a dentist's chair. If they selected 'no barriers,' ask what keeps their routine consistent instead.

Q10
Opinion Scale

If you currently have a regular dentist or dental provider, how likely are you to recommend them to a friend or family member?

Scale: 0 – 10
Min:Not at all likelyMax:Extremely likely
Q11
Multiple Choice

What is your age range?

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

What is your gender?

  • Woman
  • Man
  • Non-binary
  • Prefer not to say
Q13
Dropdown

Do you currently have dental insurance?

  • Yes, private insurance
  • Yes, public/government insurance
  • No insurance
  • Not sure
  • Prefer not to say
Q14
Message

Thank you for sharing your oral health habits and experiences! Your responses will be combined with others to help improve dental care access and everyday oral care guidance.

What’s included

  • AI follow-ups

    Adaptive probes on open-ended answers that pull out detail a static form would miss.

  • Attention checks

    Built-in safeguards against rushed answers and low-quality respondents.

  • AI-drafted copy

    Wording, ordering, and branching written by the AI — tuned to your research goal.

  • Auto report

    Themes, quotes, and a plain-English summary write themselves once responses come in.

How it compares

We reviewed the closest templates from other survey tools. Here’s what they do well — and where this template goes further.

Why this template

  • Goes beyond frequency checkboxes by including an AI follow-up interview that probes the respondent's specific flagged symptom or barrier to uncover the real reason behind it
  • Covers the full picture in one flow: brushing/flossing frequency, a symptom matrix (bleeding, sensitivity, etc.), last checkup timing, visit satisfaction and rating, and barriers to care
  • Includes a loyalty-style opinion scale on likelihood to keep seeing their current provider, useful for practices and oral care brands tracking retention
  • Built-in demographic and insurance-status questions let dental practices and public health researchers segment findings without extra custom fields

SurveySparrow

Oral Hygiene Survey Template

A ready-to-field oral hygiene survey template covering habits and satisfaction, built on SurveySparrow's conversational form format. It's a static question set rather than an interview, so answers are limited to what's pre-written. Good for quick fielding but not for digging into why a respondent flagged a specific symptom or barrier.

What it does well

  • Conversational, chat-style UI that can feel more engaging than a plain form
  • Ready-to-use template requiring no build-from-scratch effort
  • Part of a broader survey platform with reporting and distribution tools

Where it falls short

  • No adaptive follow-up questioning — every respondent sees the same fixed question set
  • No mention of AI-driven probing into individual symptoms or barriers
  • No published methodology or prompt transparency for how questions were designed

QuestionPro

Oral Health Survey Questions + Sample Questionnaire Template

A sample questionnaire and question bank for oral health topics, positioned more as a reference guide with example questions than a single polished, ready-to-launch survey. Useful for researchers who want to build their own instrument, but it requires manual assembly and customization. No interview or follow-up capability is described.

What it does well

  • Broad library of sample oral health questions to draw from
  • Backed by an established survey platform with standard reporting features
  • Flexible for researchers wanting to construct a custom questionnaire

Where it falls short

  • Reads as a question-bank/guide rather than a single fielding-ready template
  • No adaptive or voice AI interview to explore individual respondent context
  • No automated per-response quality scoring described

Ready to launch?

Open this template in the editor. Every part is yours to change before the first respondent sees it.

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