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Gender?
 
Female
 
Male

 
 
 
Age:
 
18 to 28
 
29 to 39
 
40 to 50
 
51 to 61
 
62 to 72
 
Over 72
 
 
 
Ethnic group:
 
White British
 
White Irish
 
Other white background
 
White and black Caribbean
 
White and black African
 
White and Asian
 
Other mixed background
 
Asian or Asian British Indian
 
Asian or Asian British Pakistani
 
Asian or Asian British Bangladeshi
 
Other Asian background
 
Black or black British Caribbean
 
Black or black British African
 
Other black background
 
Chinese
 
Any other ethnic group
 
Arab
 
 
 
Education:
 
Primary school
 
Secondary school
 
College
 
Higher education/ university
 
specify:
 
 
 
 
If you are currently at work, please tick which best describes your employment:
 
Labourer
 
Semi-skilled
 
Skilled
 
Managerial
 
Professional
 
Other
 
 
 
 
Do you currently have a dentist?
 
Yes
 
No
 
In the process of looking
 
 
 
If you don't have a dentist please specify a reason?
   
 
 
 
If you have a dentist, is it NHS or private?
 
NHS
 
Private
 
Other
 
 
 
 
Are you eligible for free NHS treatment
 
Yes
 
No
 
i don't know
 
 
 
When was your last check-up?