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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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Dental Screening & Oral Health Check-In Survey
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.
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Sample questions
A preview of what’s in the template. Every question is editable before you launch.
12 questions · ~8 min
Q01
Multiple ChoiceRequired
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
Q02
Multiple ChoiceRequired
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
Q03
MatrixRequired
In the last 3 months, how often have you experienced any of the following?
5 rows × 4 columns
- Tooth pain or sensitivity
- Bleeding or swollen gums
- Bad breath
- Jaw pain or clicking
- Difficulty chewing
Columns: Never · Rarely · Sometimes · Often
Q04
Multiple ChoiceRequired
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
Q05
Multiple ChoiceRequired
In the last week, how often did you floss or use an interdental cleaner?
- Never
- 1-2 times
- 3-5 times
- Every day
Q06
Opinion ScaleRequired
Overall, how would you rate the current health of your teeth and gums?
Scale: 1 – 7
Min:Very poorMax:Excellent
Q07
Rating Scale
How anxious or uncomfortable do you typically feel about dental visits?
Range: 1 – 5
Min:Not at all anxiousMax:Extremely anxious
Q08
AI Interview
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.
Q09
Multiple Choice
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
Q10
Multiple Choice
Do you currently have dental insurance or a dental benefit plan?
- Yes
- No
- Not sure
Message
Just a couple of quick background questions to finish up.
Q11
Multiple Choice
What is your age group?
- 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 to self-describe
- Prefer not to say
Message
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.
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 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 TemplateA 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.
What it does well
- 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
Where it falls short
- 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 FormTypeform 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.
What it does well
- Clean, mobile-friendly conversational form design
- Easy to customize branding and question wording
- Fielding-ready template usable immediately
Where it falls short
- 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
Frequently asked questions
What questions are in the “Dental Screening & Oral Health Check-In Survey” template?
The template includes 12 ready-to-use questions, starting with: “When was your last dental visit (checkup, cleaning, or treatment)?” · “What is the main reason for this dental visit?” · “In the last 3 months, how often have you experienced any of the following?”. The full set is previewed above, and every question is editable.
How long does this survey take to complete?
Respondents typically finish the 12 questions in about 8 minutes.
Can I customize this template?
Yes — every question, answer option, and the ordering is editable before you launch. You can add or remove questions, or ask the AI editor to rework the survey around your research goal.
Is this template free to use?
Yes. Open it in the editor and start customizing right away — no account required to try it, and the free plan covers launching your survey.
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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