Respondent sequence number
When did you last visit a dentist
Main reason for last dental visit
Amount of saliva in mouth
Mouth feel dry when eating meal
How often last yr. had aching in mouth?
How often felt bad because of mouth?
Last yr had diff w/ job because of mouth
Last yr taste affected because of mouth
Last yr avoid some food because of mouth
Last yr couldn't eat because of mouth
Last yr embarrassed because of mouth
Need any teeth filled or replaced?
Do you or SP need teeth pulled?
Need teeth pulled because of pain
Need teeth pulled because of cavities
Need teeth pulled because of lost fillin
Need teeth pulled because of gum probs
Need teeth pulled because of appearance
Need teeth pulled because of other
Do you or SP need dentures made?
Do you or SP need gum treatment?
Do you or SP need relief of pain?
Do you or SP need teeth cleaned?
How long since had teeth cleaned
Past yr need dental but couldn't get it
Could not afford the cost
Did not want to spend the money
Insurance did not cover procedures
Dental office is too far away
Office not open at convenient time
Another dentist recommended not doing it
Afraid or do not like dentists
Unable to take time off from work
Too busy
Expected dental problems to go away
Other