Name : Date :1. Have you ever been to a dentist ?- Yes(- No(- Don’t have a dentist(2. How do you select a dentist ?- Ask friends, neighbors, co-workers(- Enquire on yellow pages / just dial(- Ask your family doctor(- Closest to the place of residence(- Any Other _________________________________________3. How occasionally do you visit a dentist ?- Once a year(- Twice a year(- More than 2 times a year(- Only in emergencies(4.
Are there any apprehensions in your mind before visiting a dentist ? – Apprehensions related to pain(- Apprehensions related to price(- Apprehensions related to hygiene(- Apprehensions related to technology(- Any Other _________________________________________5. Which dentist do you visit ? ________________________________________________________6. Since when are you visiting the dentist ?- 1 – 3 years(- 3 – 5 years(- 5 – 7 years(- More than 7 years(7. Any particular reason for visiting the above mentioned dentist ? ________________________________________________________8. How satisfied are you with your dentist ?( |( |( |( |( |( |( | |Very Satisfied | | | | | |Dissatisfied | |9. What do you find the least appealing about your dentist ? – Price(- Lack of technology(- Behavior of the dentist(- Pain(- Lack of convenience of time(- Lack of hygiene(- Ambience(- None of the above(10. How important are the following factors when selecting a dentist? ( Rank them in the order of importance ) – Affordability__- Technology__- Qualified Staff__- Reduced Pain__- Convenience Of Time__- Hygiene__- Ambience__11.
If you have to consider visiting a new dental clinic within your vicinity, what would be the reasons for the same ? (Tick all those options which apply)- Affordability(- Technology(- Qualified Staff(- Reduced Pain(- Convenience Of Time(- Hygiene(- Ambience(- Any other __________________________________________ 12. Any suggestions on improving the experience of visiting a dentist ________________________________________________________