Survey Text

1983
1971
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1983
Survey form view entire document:  text  image

Complete a separate column for each 2-week dental visit.
2a. (Earlier I was told -- went to the dentist during the 2 week period beginning Monday, (date) and ending Sunday, (date).)
{Now I am going to read a list of dental services.}
When -- went to the dentist ([the last time/the time before that]) did -- have:
A. An x-ray taken?
B. A tooth filled?
C. A tooth pulled?
D. Any other oral surgery?
E. A fluoride treatment?
F. Teeth cleaned?
G. Teeth straightened, that is, orthodontia?
H. Treatment for gums?
I. Work done on a complete denture?
J. Work done on a partial denture?
K. Work done on a bridge?
L. Work done on a crown or cap?
M. Work done on a root canal?
N. An examination?
O. Something else done?
[the brackets represents 1,2,3 visits for each procedure]

A. [] [] [] X ray
B. [] [] [] Filled
C. [] [] [] Pulled
D. [] [] [] Oral surgery
E. [] [] [] Fluoride
F. [] [] [] Cleaned
G. [] [] [] Straightened
H. [] [] [] Gums
I. [] [] [] Complete denture
J. [] [] [] Partial denture
K. [] [] [] Bridge
L. [] [] [] Crown or cap
M. [] [] [] Root canal
N. [] [] [] Examination
O. [] [] [] (Specify, then reask O)
Visit 1 ____
Visit 2 ____
Visit 3 ____

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1971
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8a. During the past 2 weeks, did anyone in the family, (that is you, your --, etc.) go to a dentist?
[] Y (8b and c)
[] N (10)


b. Who was this? -- Mark "Dental visit," box in person's column. ____
[] Dental visit


c. During the past 2 weeks, did anyone else in the family go to a dentist?
[] Y (Reask 8b and c)
[] N


If "Dental visit," ask:

d. During the past 2 weeks, how many times did -- go to dentist?
No. of dental visits ____ (NP)


For each dental visit, ask:

9a. What did -- have done (the last time, the time before, etc.)? (Mark all that apply for each visit)


[Columns 1-3 for different people omitted here]


[] Cleaning teeth
[] Exam. (X-ray)
[] Fillings
[] Extractions or other surgery
[] Straightening (Orthodontia)
[] Treatment for gums
[] Denture work
[] Other (Describe) ________


b. Anything else?
[] Cleaning teeth
[] Exam. (X-ray)
[] Fillings
[] Extractions or other surgery
[] Straightening (Orthodontia)
[] Treatment for gums
[] Denture work
[] Other (Describe) ________