Section 1: Demographics
A. How old are you?
B. What is your gender identity?
Select an option
Male
Female
C. What is the highest degree or level of school you have completed?
Select educational level
Grade school, High school, or No formal education
College graduate, Graduate school, or University
Section 2: CDC/AAP Self-Reported Oral Health Questions
Q1. Do you think you might have gum disease?
Select an option
Yes
No
Refused
Don’t Know
Q2. Overall, how would you rate the health of your teeth and gums?
Select an option
Excellent
Very good
Good
Fair
Poor
Refused
Don’t Know
Q3. Have you ever had treatment for gum disease, such as scaling and root planing, sometimes called ‘‘deep’’ cleaning?
Select an option
Yes
No
Refused
Don’t Know
Q4. Have you ever had any teeth become loose on their own, without an injury?
Select an option
Yes
No
Refused
Don’t Know
Q5. Have you ever been told by a dental professional that you lost bone around your teeth?
Select an option
Yes
No
Refused
Don’t Know
Q6. During the past 3 months, have you noticed a tooth that doesn’t look right?
Select an option
Yes
No
Refused
Don’t Know
Q7. Aside from brushing your teeth with a toothbrush, in the last 7 days, how many times did you use dental floss or any other device to clean between your teeth?
Select an option
Yes (Used it)
No (Did not use)
Q8. Aside from brushing your teeth with a toothbrush, in the last 7 days, how many times did you use mouthwash or other dental rinse product that you use to treat dental disease or dental problems?
Select an option
Yes (Used it)
No (Did not use)