Ohrqol instrument knust- irb number version …/ /2010



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OHRQOL Instrument KNUST- IRB Number ……….

Version …/.../2010






Oral Health Related Quality of Life

Child Perception Questionnaire
logos

Date: …../…../2010 Study Code: ………



Thank you very much for answering a few questions

about your teeth and why you are here today.

  1. How Happy or Unhappy are you right now?

1 2 3 4 5

Very Unhappy Unhappy Neither Happy Happy Very Happy

nor Unhappy

If Unhappy, please, tell me why you are not happy?


  1. Now we ask you some questions about your teeth:

  1. Do your teeth hurt you now? Yes No

  2. Do your teeth hurt when you eat something hot or cold? Yes No

  3. Do your teeth hurt when you eat something sweet? Yes No

  4. Do your teeth hurt when you chew or bite? Yes No



  1. Does a hurting tooth ever wake you up at night? Yes No

  2. Does a hurting tooth ever stop you from playing? Yes No

  3. Does a tooth ever hurt you while you are in school? Yes No

  4. Does a hurting tooth ever keep you home from school? Yes No

  5. Does a hurting tooth ever keep you from learning in school? Yes No

  6. Does a hurting tooth ever keep you from paying attention in school? Yes No



  1. Do you like your teeth? Yes No

  2. Do you have a nice smile? Yes No

  3. Do kids make fun of your teeth? Yes No

  4. Are you happy with your teeth? Yes No

If no, please, tell me why you are not happy?

  1. Do you clean your teeth? Yes No

  2. Do you use a miswak? Yes No

  3. Do you have your own toothbrush? Yes No



  1. About the treatment today:

These questions are about your treatment today. For each topic we mention please tell us how afraid you are. Tell us if you are not afraid at all, a little afraid, a fair amount, pretty much afraid, or very afraid.

Not at A little A fair Pretty Very

Item All afraid amount much afraid
Doctor …… …… …… …… ……

Having somebody examine your mouth …… …… …… …… ……

Having to open your mouth …… …… …… …… ……

Having somebody look at you …… …… …… …… ……

Instruments in your mouth …… …… …… …… ……

Choking from things in your mouth …… …… …… …… ……



Having someone clean your teeth …… …… …… …… ……

Is there anything else you want to tell us about your teeth?

Thank you very much for answering these questions.


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