Dental Needs of the Homeless

Survey Form

Instruction:
Please read the questions below and answer the questions carefully. The information you will
provide will be treated confidential and will be used for research purposes.

1. Where do you get access for emergency care?

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2. Do you understand your right to access NHS?

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3. Is it easy to find this access for dental care?

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4. How important is dental restoration to you?

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5. Did you have your teeth removed by a medical professional?

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6. Do you have access to dental cleaning materials?

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7. How do you treat dental pain?

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8. Do you visit the dentist only when in pain?

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9. Why don't you go to the dentist regularly?

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10. What do you think can be done to improve dentistry for the homeless?
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Complete Name and Signature Date