Attachment 11 Oral Health Questionnaire

Attachment 11

Oral Health Questionnaire

OMB no. 0920-0237

Expires: 11/30/2009

Notice - Information contained on this form which would permit identification of any individual or establishment has been collected with a guarantee that it will be held in strict confidence, will be used only for purposes stated for this study, and will not be disclosed or released to others without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m). Public reporting burden of this collection of information is estimated to average 4 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-74, Atlanta, GA 30333. ATTN: PRA (0920-0214).

To be ask only to adults age 30 years and older

1. OHQ005 [NEW]. Have you lost all of your upper and lower natural (permanent) teeth?

1 = Yes

2 = No

7 = Refused

9 = DK

If “1” or “7” then skip to END of OH section

[Note: OHQ from NHIS 1999, 2000, 2001, 2002]

2. OHQ010. Has the doctor or dentist ever told you that you must ALWAYS take antibiotics (e.g. penicillin) before you get a dental check up or dental care?

1 = yes

2 = no

3. OHQ043 [NEW]. Do you have an artificial heart valve?

1 = yes
2 = no

4. OHQ033 [NEW]. Have you had heart disease since birth?

1 = yes

2 = no

[Note: MVP no longer recommended for exclusion]

5. OHQ063 [NEW]. Have you had a bacterial infection of the heart, also called Bacterial Endocarditis?

1 = yes
2 = no

“Has a doctor ever told you that you have:”

6. OHQ070. Rheumatic fever?

1 = yes
2 = no

7. SEXHEMO. Hemophilia?

1 = yes
2 = no

8.OHQ080. Kidney disease requiring renal dialysis?

1 = yes
2 = no

9. SEXPACE. A pacemaker or automatic defillibrator?

1 = yes
2 = no

10. OHQ110. A hip bone or joint replacement?

1 = yes
2 = no

For this section, if YES to any question skip to END of OH Section

“Gum disease is a common problem with the mouth. People with gum disease might have swollen gums, receding gums, sore or infected gums or loose teeth.”

11. OHQB010. Do you think you might have gum disease?

1=Yes

2=No

7=Refused

9=Don’t Know

12. OHQB020. Overall, how would you rate the health of your teeth and gums?

1=Excellent

2=Very good

3=Good

4=Fair

5=Poor

7=Refused

9=Don’t Know

13. OHQB030. Have you ever had treatment for gum disease such as scaling and root planing, sometimes called “deep cleaning?”

1=Yes

2=No

7=Refused

9=Don’t Know

14. OHQB040. Have you ever had any teeth become loose on their own, without an injury?

1=Yes

2=No

7=Refused

9=Don’t Know

15. OHQB050. Have you ever been told by a dental professional that you lost bone around your teeth?

1=Yes

2=No

7=Refused

9=Don’t Know

16. OHQB060. During the past three months, have you noticed a tooth that doesn’t look right?

1=Yes

2=No

7=Refused

9=Don’t Know

17. OHQB070. Aside from brushing your teeth with a toothbrush, in the last seven days, how many times did you use dental floss or any other device to clean between your teeth?

___: Number of days

77=Refused

18. OHQB080. Aside from brushing your teeth with a toothbrush, in the last seven days, how many times did you use mouthwash or other dental rinse product that you use to treat dental disease or dental problems?

___: Number of days

77=Refused

End Oral Health Section

21 November 2007

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