NDO QUESTIONNAIRE

Date//

Please fill in all blank.
First Name
Sex

Family Name
MaleFemale

Nationality

Birthday (Age)()

Occupation

Home Address
Mobile Phone No.

Home Telephone No.

＠Email address

You are a ( permanent resident / temporary resident (until//Do you have a Japanese National Health Insurance?

( Yes/No )Which language do you prefer to communicate in?

( English /) / traveller )Japanese / Neither )How did you know about our dental office?
どのようにして当院を知りましたか？

What is the matter with you today?
今日はどうされましたか？

When was your last dental visit?
最後に歯科を受診されたのはいつですか？

What was your last dental visit?
最後に歯科を受診した際、何をしましたか？

Do you have pain? □ NO

□YES → Please fill another ”NDO Pain Questionnaire”

痛みはありますか？

Are you taking any medicine?
薬を飲んでいますか？

Do you have allergy to any medications or dentophobia?
薬のアレルギーや歯科恐怖症はありますか？

Do you have any systemic disease ?
全身的な病気はありますか？

Do you have any other present illness?
今、他に何か病気にかかっていますか？

If you have had infectious disease before, please describe it.
過去に感染症にかかったことはありますか？

Do you have any request for the Dr?
何か、ドクターにリクエストはありますか？

Oral Health Impact Profile（OHIP-14）
1. Have you had trouble pronouncing any words because of problems withyour teeth, mouth or denture?

Never

Hardly everOccasionally

Fairy often

Very often

Never

Hardly everOccasionally

Fairy often

Very often

4. Have you found it uncomfortable to eat any foods because of problems

Never

Hardly everOccasionally

Fairy often

Very oftenwith your teeth, mouth or denture?

Never

Hardly everOccasionally

Fairy often

Very often

6. Have you felt tense because of problems with your teeth, mouth or

Never

Hardly everOccasionally

Fairy often

Very often

denture?

Never

Hardly everOccasionally

Fairy often

Very often

7. Has your diet been unsatisfactory because of problems with your teeth,

Never

Hardly everOccasionally

Fairy often

Very often

Never

Hardly everOccasionally

Fairy often

Very often

Never

Hardly everOccasionally

Fairy often

Very often

Never

Hardly everOccasionally

Fairy often

Very often

Never

Hardly everOccasionally

Fairy often

Very often

Never

Hardly everOccasionally

Fairy oftenVery often

Never

Hardly everOccasionally

Fairy often

Very often

Never

Hardly everOccasionally

Fairy often

Very often

2. Have you felt your sense of your taste has worsened because of problems
with your teeth, mouth or denture?
3. Have you had painful aching in your mouth?

5. Have you been self conscious because of your teeth, mouth or denture?

mouth or dentures?
8. Have you had interrupt meals because of problems with your teeth,
mouth or dentures?
9. Have you found it difficult to relax because of problems with your teeth,
mouth or dentures?
10. Have you been a bit embarrassed because of problems with your teeth,
mouth or dentures?
11. Have you been a bit irritable with other people because of problems withyour teeth, mouth or dentures?
12. Have you had difficulty doing your usual jobs because of problems withyour teeth, mouth or dentures?
13. Have you felt that life in general was less satisfying because of problems
with your teeth, mouth or dentures?
14. Have you been totally unable to function because of problems with yourteeth, mouth or dentures?