QUESTIONNAIRE

NAME :
AGE
:
GENDER:

Mr./Ms.____________________
__________years.

DATE:

MALE
FEMALE

1) Do you consume tobacco?

YES
NO
2) When did you start consuming tobacco?
___________________________________________________________________________

3) How frequently do you consume it?

___________________________________________________________________________
4) What makes you consume it?
___________________________________________________________________________
5) How do you feel before and after consuming tobacco?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
6) Are you aware of the diseases and consequences that arise due to tobacco chewing?
YES
NO
7) Do you have any of these health problems?
STAINS ON TEETHS
GUM IRRITATION
TOOTH ACHE
TOOTH SENSITIVITY
8) Do you consume it in front of your kids?
YES
NO

9) Would you accept if your children consume it?

YES
NO

10) How much do you spend on it per day?

___________________________________________________________________________

11) Are you planning to quit? If YES then what measures have you enforced?
YES
NO
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

ANALYSIS/FEEDBACK
YEARLY EXPENDITURE: ______* 365=______
LEVEL OF SUSCEPTIBILITY TO DISEASES:
PERCIEVED ORAL HEALTH:
RECOMMENDED STRATEGY FOR QUITTING TOBACCO CONSUMPTION: