Fluoride Needs Assessment
Help us evaluate your fluoride exposure and oral health needs by answering the following questions.
Full Name
*
First Name
Last Name
Age
*
Email Address
example@example.com
What is your primary source of drinking water?
*
Public tap water
Well water
Bottled water
Filtered water
Other
How often do you brush your teeth?
*
Twice or more daily
Once daily
A few times a week
Rarely or never
What type of toothpaste do you use most often?
*
Fluoride toothpaste
Non-fluoride toothpaste
Herbal/Natural toothpaste
Not sure
Have you or your children had dental cavities (tooth decay) in the past year?
*
Yes
No
Not sure
How often do you visit a dentist?
*
Twice a year or more
Once a year
Less than once a year
Never
Please rate the following statements based on your agreement.
Rows
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Fluoride helps prevent tooth decay
1
2
3
4
5
I am concerned about fluoride safety
6
7
8
9
10
I have enough information about fluoride
11
12
13
14
15
I prefer using fluoridated toothpaste
16
17
18
19
20
How would you rate your overall knowledge about fluoride?
1
2
3
4
5
Do you or your children regularly consume any of the following? (Select all that apply)
Tea
Processed foods
Juices
Bottled drinks
None of the above
Is there anything else you would like to share about your household's fluoride needs or oral health?
Submit Assessment
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