|1||What age was your child at their very first dental visit:|
|2||What first motivated you to bring them to the dentist?|
|3||Where did your child attend the dentist?|
|4||What concerned you most about your child’s teeth? Please Rank from 1–6 (1 being of most concern and 6 of least concern): Function; Speech; Reaction of other children; Reaction of other parents; Your child’s reaction (self-conscious); How the teeth look|
|5||In your opinion, has your child ever been self-conscious about their teeth? If yes, please specify at what age?|
|6||How many dental visits has your child had? Response options: Less than 5 visits/5–10 visits/10–20 visits/20 or more visits|
Was your child cooperative for dental visits?|
If you answered ‘No’, Why do you think your child was not cooperative?
Where did you get information about your child’s dental condition?|
Did you receive enough information?
|9||Please specify what additional Information needed:|
|10||If you could start from the beginning again, what would you change?|