Resporden = Aritic Indah Marnayux C21lotee015) 960 | 7 \nterviewer> Aina Satsabiea (Silo\fooces ). SGD \ Annex Health: Oganesicn Oral Health Questionnaire for Adults Identification number Sex Location Male Female Usban—Periurban Rural 1, PEE Z 1 4 1 2 1 2 + 2. How old are you today? __!@ tamu (Years) 3. How many natural teeth do you have? No natural teeth. 1-9 teeth 10-19 teeth . 20 teeth or more. 4, During the past 12 months, did your teeth or mouth cause any pain or discomfort? a1 o2 o9 ao No answer. 5. Do you have any removable dentures? ‘Yes 1 A partial denture?... Q A full upper denture? o A full lower denture? ... = Gl 6. How would you describe the state of your teeth and gums? Is it “excellent”, “very good”, “good”, “average”, “poor”, or “very poor”? Teeth Gums Excellent Ga q1 Very good 02 oO2 Good 03 3 Average 24 04 Poor. 05 5 Very poor ‘06 6o6 Don’t know oo Ao iuAnnex 7 7. How often do you clean your teeth? Never... Once a month 2-3 times a mont Once a week.. 2-6 times a weel Once a day. ‘Twice or more a day 8. Do you use any of the following to clean your teeth? (Read each item) ‘Toothbrush..... ‘Wooden toothpicks .. Plastic toothpicks? ‘Thread (dental floss) Charcoal Chewstick/miswak. Other... Please specify oooDoooe~¥F 9. a) Do you use toothpaste to clean your teeth b) Do you use a toothpaste that contains fluoride? Don’t know . 10. How long is it since you last saw a dentist? Less than 6 months . 6-12 months .. More than 1 year but less than 2 years 2 years or more but less than 5 years 5 years or more .. Never received dental care 11. What was the reason of your last visit to the dentist? Consultation/advis Pain or trouble with teeth, gums or mouth. Treatment follow-up treatment . Routine check-up/treatment. Don’t know/don’t remember. 112Oral Health Surveys Basic Methods 12 months? (@) Difficulty in biting foods (b) Difficulty chewing foods. (© Difficulty with speech/trouble pronouncing words .. (a) Dry mouth... (©) Felt embarrassed due to appearance of teeth... (® Felt tense because of problems with teeth or mouth... (g) Have avoided smiling because of teeth (h) Had sleep that is often interrupted . () Have taken da (k) Felt less tolerant of spouse or people who are close to you... @ Have reduced participation in social activities. 72. Because of the state of your teeth or mouth, you experienced any of the following problems during the past G) Difficulty doing usual activities. how often have Very Fairly Some- Don’t often often times No know 4 3 2 4 0 ee ore o oO bn ff oe oo oe oo oo oe oe o oF OF Bf Oo be oe Ge o06U6uOdlUcOlUB a a Ge oo Q a Oo @ o fo eo oe oo in small quantities? (Read each item) 13. How often do you eat or drink any of the following foods, even Several Several Several times Every times Once times Seldom aday day aweek aweeck a month /never 6 2 4 3 2 1 Fresh fru Boo ob Ge Biscuits, cakes, cream cakes... as El oO oO ey Qo Seepetme oo oo | a Jam or honey ., Po og oo a o Chewing gum containing sugar... 8 OF O a Qo Sweets/candy, B09 8 a o 113Annex 7 ‘Lemonade, Coca Cola or other soft drinks. oO) oa o a ‘Tea with sugar Ba a a ao Coffee with sugar a a o oa a yY nsert country-specific items) 14. How often do you use any of the following types of tobacco? (Read each item) Several Several Every times Once times day a week aweck amonth Seldom Never 6 & 4 a 2 1 Cigarettes. oO fa a Cigars -O G oo oO ao 6 A pipe -O og a o @ Chewing tobacco... a oo o @ Use snuff. ‘a a oa a ao ada -O go 60h o @ Please specify 15. During the past 30 days, on the days you drank alcohol, how many drinks did you usually drink per day? Less than 1 drink : i .00 at 2 ene 5 or more drinks .. Did not drink alcohol during the past 30 days 16. What level of education have you completed? No formal schooling Less than primary school. Primary school completed Secondary school completed. High school completed. College/university completed Postgraduate degree . (Insert country-specific categories) That completes our questionnaire Thank you very much for your cooperation! Year Month OD: fy Inverter District 4 ‘gl fe @ ° 114