Patient Questionnaire

Practice Name

Doctor Name

1. Before you came to our practice, have you ever had a thorough Oral Head & Neck Exam – hygienist/dentist palpated your neck, pulled your tongue, asked you to say Ahh, etc.?

Likert Scale

	Not Important	Somewhat Important	Neutral	Important	Very Important
Do you feel you understand how important a thorough oral examination is?	Not ImportantDo you feel you understand how important a thorough oral examination is? Not Important	Somewhat ImportantDo you feel you understand how important a thorough oral examination is? Somewhat Important	NeutralDo you feel you understand how important a thorough oral examination is? Neutral	ImportantDo you feel you understand how important a thorough oral examination is? Important	Very ImportantDo you feel you understand how important a thorough oral examination is? Very Important
How do you feel that the same virus (Human Papilloma Virus (HPV)) that causes Cervical Cancer, is now the leading cause of oral pharyngeal cancer effecting both men and women of all ages?	Not ImportantHow do you feel that the same virus (Human Papilloma Virus (HPV)) that causes Cervical Cancer, is now the leading cause of oral pharyngeal cancer effecting both men and women of all ages? Not Important	Somewhat ImportantHow do you feel that the same virus (Human Papilloma Virus (HPV)) that causes Cervical Cancer, is now the leading cause of oral pharyngeal cancer effecting both men and women of all ages? Somewhat Important	NeutralHow do you feel that the same virus (Human Papilloma Virus (HPV)) that causes Cervical Cancer, is now the leading cause of oral pharyngeal cancer effecting both men and women of all ages? Neutral	ImportantHow do you feel that the same virus (Human Papilloma Virus (HPV)) that causes Cervical Cancer, is now the leading cause of oral pharyngeal cancer effecting both men and women of all ages? Important	Very ImportantHow do you feel that the same virus (Human Papilloma Virus (HPV)) that causes Cervical Cancer, is now the leading cause of oral pharyngeal cancer effecting both men and women of all ages? Very Important
Now that you have had a VELscope (blue light) exam to see potential changes that are not obvious to the naked eye, would you recommend your friends and family have a VELscope examination?	Not ImportantNow that you have had a VELscope (blue light) exam to see potential changes that are not obvious to the naked eye, would you recommend your friends and family have a VELscope examination? Not Important	Somewhat ImportantNow that you have had a VELscope (blue light) exam to see potential changes that are not obvious to the naked eye, would you recommend your friends and family have a VELscope examination? Somewhat Important	NeutralNow that you have had a VELscope (blue light) exam to see potential changes that are not obvious to the naked eye, would you recommend your friends and family have a VELscope examination? Neutral	ImportantNow that you have had a VELscope (blue light) exam to see potential changes that are not obvious to the naked eye, would you recommend your friends and family have a VELscope examination? Important	Very ImportantNow that you have had a VELscope (blue light) exam to see potential changes that are not obvious to the naked eye, would you recommend your friends and family have a VELscope examination? Very Important
Understanding the importance of a thorough Oral Cancer exam with a VELscope, how essential do you think offering this should be when choosing a dentist?	Not ImportantUnderstanding the importance of a thorough Oral Cancer exam with a VELscope, how essential do you think offering this should be when choosing a dentist? Not Important	Somewhat ImportantUnderstanding the importance of a thorough Oral Cancer exam with a VELscope, how essential do you think offering this should be when choosing a dentist? Somewhat Important	NeutralUnderstanding the importance of a thorough Oral Cancer exam with a VELscope, how essential do you think offering this should be when choosing a dentist? Neutral	ImportantUnderstanding the importance of a thorough Oral Cancer exam with a VELscope, how essential do you think offering this should be when choosing a dentist? Important	Very ImportantUnderstanding the importance of a thorough Oral Cancer exam with a VELscope, how essential do you think offering this should be when choosing a dentist? Very Important

VELscope Testimonial

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Patient Questionnaire

LED Dental, Inc

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