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An Example of a Questionnaire

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“Effects of Poor oral hygiene”

Direction: This questionnaire aims to know the answers provided by the correspondents about the effects of poor oral hygiene. Kindly answer all the questions. Please check the box to answer.

Name: _________________________________________
Age: ____ Signature: _______________________ A. Check YES if you agree or check NO if you don’t. Yes No 1. Do you know what Poor oral hygiene means? 2. Are you aware of the effects of poor oral hygiene? 3. Can you maintain a good oral hygiene? B. Read the questions carefully and answer by checking the box. 4. How many times do you brush your teeth in a day? 3 times a day 2 times a day I never brush my teeth Other answers. Please specify: ___________________ 5. Do you have Tooth Decay? Yes No 6. Why do you think you have Tooth Decay? Because I feel that there is something wrong with my teeth Because I don’t brush my teeth When I went to the dentist, she/he told me I have tooth decay I don’t have Tooth Decay 7. Which of the following are you using to brush your teeth? Toothbrush Oral Medicines Other answers. Please specify: ________________________ 8. Can Poor Oral Hygiene affect a person’s behaviour? Yes No 9. How does Poor Oral Hygiene affect a person’s behavior? It will make him/her unable to communicate with others He/she will lose his/her self-esteem and self-confidence. It will make him/her lonely. Other answers. Please specify:

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