Q01
Message
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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.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
13 questions · ~7 min
Q02
Multiple ChoiceRequired
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
Multiple ChoiceRequired
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
MatrixRequired
In a typical week, how often do you do each of the following?
3 rows × 5 columns
- Brushing your teeth
- Flossing
- Using mouthwash
Columns: Never · A few times a week · Once a day · Twice a day · More than twice a day
Q05
Opinion ScaleRequired
How would you rate the current health of your teeth and gums?
Scale: 1 – 10
Min:PoorMax:Excellent
Q06
Multiple Choice
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
Opinion ScaleRequired
How anxious or nervous do you feel about visiting the dentist?
Scale: 1 – 7
Min:Not anxious at allMax:Extremely anxious
Q08
Multiple ChoiceRequired
In the last 12 months, has cost ever kept you from getting dental care you needed?
- Yes
- No
- Not sure
Q09
Multiple Choice
Do you currently have dental insurance or a dental benefit plan?
- Yes
- No
- Not sure
- Prefer not to say
Q10
AI Interview
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
Multiple Choice
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
Multiple Choice
What is your gender?
- Woman
- Man
- Non-binary
- Prefer not to say
Q13
Message
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.
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 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 QuestionnaireA 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.
What it does well
- 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
Where it falls short
- 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 TemplateA 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.
What it does well
- Highly customizable form builder with drag-and-drop fields
- Broad integration ecosystem (payments, e-signature, storage)
- Familiar, easy-to-complete form format for patients
Where it falls short
- 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 TemplateA 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.
What it does well
- 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
Where it falls short
- 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
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.