SURVEY QUESTIONNAIRE FOR HDML RECIPIENTS 

Date: __________________________________ 

Examiner:_____________ Subject ID: 

Good morning, Mr/Mrs/Dr __. We had an appointment today to ask you some questions 

about your mouth, teeth and dentures. Do you still have time today (If respondent replies 

“yes”, continue with interview; if “no”, ask to make an appointment for another day, and 

thank them for their participation). 

“First, some questions about where you receive dental care”

1. When was the last time you went to the dentist? How many months ago? 

Code ‘0’ for less than 2 weeks ago

Code ‘7777’ for don’t know/don’t remember 

Code ‘8888’ for refusal 

Code ‘9999’ for not applicable (never visited dentist) 

RECORD MONTHS SINCE LAST VISIT: 

2. Why did you make this visit? 

Routine care – tooth/denture cleaning/check-up 1

Emergency – toothache/aching gums/broken denture 2

Other (specify) 3

Refusal 8888

Not applicable (Never went to the dentist) 9999

3. When you do go to the dentist, where do you go? CODE ALL THAT APPLY

Private dentist’s office 1

Public dental clinic 2

Hospital dental clinic 3

Dental school clinic 4

Emergency room 5

Other (specify)_________________ 6

Don’t know 7777

Refusal 8888

Not applicable 9999

4. How do you normally get to the dentist? 

Walking 1

Bus 2

Taxi 3

Subway 4

IRB-AAAR6590 (Y02M00)

For use until: 02/29/2020

IRB Approval Date: 03/01/2019
Access-A-Ride 5

My child/friend/relative drives me 6

I drive myself 7

Other (specify) ________________ 8

Refusal 8888

Not applicable 9999

5. If you do not visit the dentist regularly (at least once a year), what are the reasons why you do 

not go? EXAMINER: PROBE PRIMARY AND SECONDARY REASON

Primary 

Reason

Second 

Reason

I wear dentures/I do not have my own teeth 1 1

I do not have time 2 2

It costs too much 3 3

I have to travel too far 4 4

I am afraid of the dentist 5 5

I don’t think I need to see a dentist 6 6

Dental treatment is not a priority for me 7 7

I am afraid I will contract a disease 8 8

I have to wait a long time at the dentist’s 

office

9 9

Other (specify)______________ 10 10

Unknown 7777 7777

Refusal 8888 8888

Not applicable (visits dentist regularly) 9999 9999

6. Do you have all your teeth? 

Yes 0

No 1

If no: are you missing all your upper teeth? 

Yes 0

No 1

If no: are you missing all your lower teeth? 

Yes 0

No 1

7. Do you wear dentures? 

Yes 0

No 1

If yes: do you have upper dentures, lower dentures, or both? 

Upper Only 0 

Lower Only 1 

Both 2 

IRB-AAAR6590 (Y02M00)

For use until: 02/29/2020

IRB Approval Date: 03/01/2019
8. Do you brush your teeth and/or your dentures yourself, or do you need assistance 

I brush my teeth and/or dentures myself 1

My home health aide assists me with brushing my teeth and/or 

dentures

2

A family member or friend assists me with brushing my teeth and/or 

dentures

3

Unknown 7777

Refusal 8888

Not applicable (does not brush teeth and/or dentures) 9999

I will now ask you some questions about your teeth, mouth or dentures 

Over the past 12 months... Very 

often

Fairly 

often

Occasionally Hardly 

ever

Never DK N/A

*11

.

Have you had difficulty chewing any foods because of 

problems with your teeth, mouth or dentures?

4 3 2 1 0 7777 9999

12. Have you had trouble pronouncing any words because 

of problems with your teeth, mouth or dentures? 

4 3 2 1 0 7777 9999

13. Have you felt that your sense of taste has worsened 

because of problems with your teeth, mouth, or 

dentures?

4 3 2 1 0 7777 9999

14. Have you had food catching in your teeth or dentures? 4 3 2 1 0 7777 9999

15. Have you felt that your digestion has worsened 

because of problems with your teeth, mouth or 

dentures?

4 3 2 1 0 7777 9999

16. IF HAVE DENTURESL Have you felt that your 

dentures have not been fitting properly?

4 3 2 1 0 7777 9999

17. Have you had painful aching in your mouth? 4 3 2 1 0 7777 9999

18. Have you had a sore jaw? 4 3 2 1 0 7777 9999

19. Have you had headaches because of problems with 

your teeth, mouth or dentures?

4 3 2 1 0 7777 9999

20. IF HAVE TEETH: Have you had sensitive teeth, e.g. 

due to hot or cold foods or drinks?

4 3 2 1 0 7777 9999

21. IF HAVE TEETH: Have you had toothache? 4 3 2 1 0 7777 9999

22. Have you had painful gums? 4 3 2 1 0 7777 9999

*23

.

Have you found it uncomfortable to eat any foods 

because of problems with your teeth, mouth or 

dentures?

4 3 2 1 0 7777 9999

24. Have you had sore spots in your mouth? 4 3 2 1 0 7777 9999

25. IF HAVE DENTURES: Have you had uncomfortable 

dentures?

4 3 2 1 0 7777 9999

26. Have you been self-conscious because of your teeth, 

mouth, or dentures? 

4 3 2 1 0 7777 9999

27. Have you felt tense because of problems with your 

teeth, mouth, or dentures?

4 3 2 1 0 7777 9999

28. Have you felt that there has been less flavor in your 

food because of problems with your teeth, mouth, or 

dentures?

4 3 2 1 0 7777 9999

*29 Have you had to avoid eating some foods because of 

problems with your teeth, mouth or dentures?

4 3 2 1 0 7777 9999

30. Has your diet been unsatisfactory because of 

problems with your teeth, mouth, or dentures?

4 3 2 1 0 7777 9999

31. Have you had uncomfortable dentures? 4 3 2 1 0 7777 9999

32. Have you had to interrupt meals because of problems 

with your teeth, mouth, or dentures?

4 3 2 1 0 7777 9999

33. Have you found it difficult to relax because of problems 

with your teeth, mouth, or dentures? 

4 3 2 1 0 7777 9999

IRB-AAAR6590 (Y02M00)

For use until: 02/29/2020

IRB Approval Date: 03/01/2019
34. Have you been a bit embarrassed because of 

problems with your teeth, mouth, or dentures?

4 3 2 1 0 7777 9999

35. Have you been a bit irritable with other people 

because of problems with your teeth, mouth, or 

dentures? 

4 3 2 1 0 7777 9999

36. Have you had difficulty doing your usual jobs because 

of problems with your teeth, mouth, or dentures?

4 3 2 1 0 7777 9999

37. Have you felt that your general health has worsened 

because of problems with your teeth, mouth or 

dentures?

4 3 2 1 0 7777 9999

38. Have you felt that life in general was less satisfying 

because of problems with your teeth, mouth, or 

dentures?

4 3 2 1 0 7777 9999

39. Have you been totally unable to function because of 

problems with your teeth, mouth, or dentures? 

4 3 2 1 0 7777 9999

Examiner: If respondent responds to items 11, 23 and/or 29 with 4 (very often), 3 (fairly 

often) or 2 (sometimes), ask the following items: 

40. Do you have difficulty chewing fruits because of your teeth, mouth or dentures?

Yes 0 (go to 40a) 

No 1 (go to 41)

Don’t know 7777

Refusal 8888

Not applicable 9999

40a. If YES to 40 ASK: Have you also had trouble chewing fruits that come in your 

home delivered meal because of your teeth, mouth or dentures? 

Yes 0 (ask 40b & c) 

No 1 (go to 41)

Don’t know 7777

Refusal 8888

Not applicable 9999

40b. If YES to 40a ASK: Which fruits in the home delivered meal have you had trouble 

chewing because of your teeth, mouth or dentures? 

40c. If YES to 40a ASK: Have you ever had such difficulty chewing the fruit in your home 

delivered meal because of your teeth, mouth or dentures that you could not eat that part of 

the meal? 

Yes 0 (ask 40d) 

No 1 (go to 40e) 

Don’t know 7777

Refusal 8888

Not applicable 9999

IRB-AAAR6590 (Y02M00)

For use until: 02/29/2020

IRB Approval Date: 03/01/2019
40d. If YES to 40c ASK: How often in a typical week do you not eat the fruit in your home 

delivered meal due to difficulty chewing because of your teeth, mouth or dentures? 

Almost every day (5-7 times a week) 3 (go to 40e) 

Some of the time (3-4 days a week) 2 (go to 40e)

A little of the time (1-2 days a week) 1 (go to 40e)

Don’t know 7777(go to 40e)

Refusal 8888(go to 40e)

Not applicable 9999(go to 40e)

40e. Ask of Everyone: When you have difficulty chewing fruits in your home delivered 

meal, do you or someone else modify or change the fruits in any way so you can eat them 

more easily? 

Yes 0 (go to 40e) 

No 1 (go to 40f) 

Don’t know 7777

Refusal 8888

Not applicable 9999

40e. If YES to 40e ask: How do you or someone else modify the fruits in your home 

delivered meal so you can eat them? 

I cut up the food into small pieces 0

I puree the food using a blender 1

I boil or steam the food to soften it 2

Other 

(specify______________________

____________________)

3

Don’t know 4

Refusal 8888

Not applicable 9999

41. Do you have difficulty chewing vegetables because of your teeth, mouth or dentures?

Yes 0 (go to 41a) 

No 1 (go to 42)

Don’t know 7777

Refusal 8888

Not applicable 9999

41a. If YES to 41 ASK: Have you also had trouble chewing vegetables that come in 

your home delivered meal because of your teeth, mouth or dentures? 

Yes 0 (ask 41b & c) 

No 1 (go to 42)

Don’t know 7777

Refusal 8888

Not applicable 9999

IRB-AAAR6590 (Y02M00)

For use until: 02/29/2020

IRB Approval Date: 03/01/2019
41b. If YES to 41a ASK: Which vegetables in the home delivered meal have you had trouble 

chewing because of your teeth, mouth or dentures? 

41c. If YES to 41a ASK: Have you ever had such difficulty chewing the vegetables in your 

home delivered meal because of your teeth, mouth or dentures that you could not eat that 

part of the meal? 

Yes 0 (ask 41d) 

No 1 (go to 41e) 

Don’t know 7777

Refusal 8888

Not applicable 9999

41d. If YES to 41c ASK: How often in a typical week do you not eat the vegetables in your 

home delivered meal due to difficulty chewing because of your teeth, mouth or dentures? 

Almost every day (5-7 times a week) 3 (go to 41e) 

Some of the time (3-4 days a week) 2 (go to 41e)

A little of the time (1-2 days a week) 1 (go to 41e)

Don’t know 7777(go to 41e)

Refusal 8888(go to 41e)

Not applicable 9999(go to 41e)

41e. Ask of Everyone who had difficulty: When you have difficulty chewing vegetables in 

your home delivered meal, do you or someone else modify or change the vegetables in any 

way so you can eat them more easily? 

Yes 0 (go to 41f) 

No 1 (go to 42) 

Don’t know 7777

Refusal 8888

Not applicable 9999

41f. If YES to 41e ask: How do you or someone else modify the vegetables in your home 

delivered meal so you can eat them? 

I cut up the food into small pieces 0

I puree the food using a blender 1

I boil or steam the food to soften it 2

Other 

(specify______________________

____________________)

3

Don’t know 4

Refusal 8888

Not applicable 9999

IRB-AAAR6590 (Y02M00)

For use until: 02/29/2020

IRB Approval Date: 03/01/2019
42. Do have difficulty chewing meats because of your teeth, mouth or dentures?

Yes 0 (go to 42a)

No 1 (go to 43) 

Don’t know 7777

Refusal 8888

Not applicable 9999

42a. If YES to 42 ASK: Have you also had trouble chewing meats that come in your 

home delivered meal because of your teeth, mouth or dentures? 

Yes 0 (ask 42b & c) 

No 1 (go to 43)

Don’t know 7777

Refusal 8888

Not applicable 9999

42b. If YES to 42a ASK: Which meats in the home delivered meal have you had trouble 

chewing because of your teeth, mouth or dentures? 

42c. If YES to 42a ASK: Have you ever had such difficulty chewing the meats in your home 

delivered meal because of your teeth, mouth or dentures that you do not eat that part of the 

meal? 

Yes 0 (ask 42d) 

No 1 (go to 42e) 

Don’t know 7777

Refusal 8888

Not applicable 9999

42d. If YES to 41c ASK: How often in a typical week do you not eat the meats in your 

home delivered meal due to difficulty chewing because of your teeth, mouth or dentures? 

Almost every day (5-7 times a week) 3 (go to 42e) 

Some of the time (3-4 days a week) 2 (go to 42e)

A little of the time (1-2 days a week) 1 (go to 42e)

Don’t know 7777(go to 42e)

Refusal 8888(go to 42e)

Not applicable 9999(go to 42e)

IRB-AAAR6590 (Y02M00)

For use until: 02/29/2020

IRB Approval Date: 03/01/2019
42e. Ask of Everyone who had difficulty: When you have difficulty chewing meats in your 

home delivered meal, do you or someone else modify or change the meats in any way so 

you can eat them more easily? 

Yes 0 (go to 42f) 

No 1 (go to 43) 

Don’t know 7777

Refusal 8888

Not applicable 9999

42f. If YES to 42e ask: How do you or someone else modify the meats in your home 

delivered meal so you can eat them? 

I cut up the food into small pieces 0

I puree the food using a blender 1

I boil or steam the food to soften it 2

Other 

(specify______________________

____________________)

3

Don’t know 4

Refusal 8888

Not applicable 9999

43. Do you have difficulty eating nuts because of your teeth, mouth or dentures?

Yes 0

No 1

Don’t know 7777

Refusal 8888

Not applicable 9999

Next we want to ask you a general question about your home delivered meal. 

44. On a typical day do you eat:

All of the home delivered meal 0 (go to 45)

At least half of the home delivered meal 1 (go to 45)

Less than half of the home delivered 2 (ask 44a) 

Don’t know 4(go to 45)

Refusal 8888(go to 45)

44a: Is this mainly due to difficulty chewing because of your teeth, mouth or 

dentures or other health related issues?

Oral health 0

Other Health related issues 1

Don’t know 7777

Refusal 8888

IRB-AAAR6590 (Y02M00)

For use until: 02/29/2020

IRB Approval Date: 03/01/2019

Not applicable 9999
I am now going to ask you a few more questions about the last three months. 

45. In the last three months did you have problems eating due to oral or other health problems?

Yes 0

No 1

Don’t know 7777

Refusal 8888

Not applicable 9999

46. If yes, please indicate why you had problems eating (Examiner: select all that apply)

Allergies to certain foods 1

Dietary restrictions 2

General mouth pain and/or painful 

sores in the mouth

3

Illness causing pain when 

eating/digesting

4

Loose/ill fitting dentures 5

Missing teeth and no partial 

denture

6

No appetite due to medication or 

medication side effect

7

No teeth at all and no dentures 8

Problems swallowing 9

Don’t know 7777

Refusal 8888

Not applicable 9999

47. In the last three months have you been able to brush your teeth and/or clean your dentures

regularly (at least once a day)?

Yes 0

No 1

Don’t know 7777

Refusal 8888

Not applicable 9999

IRB-AAAR6590 (Y02M00)

For use until: 02/29/2020

IRB Approval Date: 03/01/2019
48. If client answered No to question 47, Examiner ask: Why not?

Cannot hold toothbrush/denture 

brush

1

Trouble remembering 2

No toothbrush/.denture brush 3

No toothpaste/denture cleaner 4

Don’t know 7777

Refusal 8888

Not applicable 9999

“We are almost finished, but now I have a few questions about you that we need for our 

records”

49. What is your date of birth?

dd/mm/yy 

50. Examiner please record subject gender

Male 0

Female 1

51. How long have you been receiving Home Delivered Meals?

 Months receiving HDM 

52. Including yourself, how many people live in your household?

Number in household

53. Were you born in the United States?

54. If not born in the United States, where were you born?

Please specify ___________________________ 

55. How long have you lived in the United States?

Number years in the US 

56. What is your race?

White 1

African-American/Black 2

Asian or Pacific Islander 3

Native American/Alaskan Native 4

Other (specify) 5

Unknown 7777

Refusal 8888

IRB-AAAR6590 (Y02M00)

For use until: 02/29/2020

IRB Approval Date: 03/01/2019
57. Are you of Spanish/Hispanic descent?

Yes 0

No 1

58. IF YES:

Do you consider yourself:

Puerto Rican 1

Cuban 2

Mexican 3

Dominican 4

Other (specify)________________ 5

Not applicable (Not Hispanic) 9999

59. How many years of school were you able to complete? (Prompt: “What was the last grade

you completed?”)

Record number of years: 

For example: 

0 No schooling 

8 Completed 8th grade 

12 Completed 12th grade 

16 Completed college 

Code 7777 if Unknown 

Code 8888 if Refusal 

60. What is the highest degree you have?

High School 1

Technical Degree 2

AA 3

BA/BS 4

MA/MS/MBA 5

Doctorate (PhD/MD/DDS/JD) 6

Other (specify)_____________ 7

Unknown 7777

Refusal 8888

Not applicable (less than high 

school)

9999

IRB-AAAR6590 (Y02M00)

For use until: 02/29/2020

IRB Approval Date: 03/01/2019
52. What type(s) of medical insurance do you have? CODE ALL THAT APPLY

Medicaid 1

Medicare 2

HMO 3

Private Health insurance 4

Don’t know 5

Other (specify) 6

Unknown 7777

Refusal 8888

Not applicable (no medical 

insurance)

9999

53. Do you have dental insurance?

Yes 0

No 1

Don’t know 2

Refusal 8888

54. If Yes, what type of dental insurance do you have?

Medicaid 1

Private dental insurance 2

Don’t know 3

Other (specify) 4

Unknown 7777

Refusal 8888

Not applicable (no dental insurance) 9999

IRB-AAAR6590 (Y02M00)

For use until: 02/29/2020

IRB Approval Date: 03/01/2019