Participant Questionnaire
Study Title: The Effectiveness of Miswak vs. Toothbrush in Oral Health Status
Instructions: Please fill out the following questionnaire to the best of your knowledge.
Your participation is voluntary, and all responses will remain confidential.
Section 1: Demographic Information
Name: ________________________________________ Age: ____________
Gender: ☐ Male ☐ Female
Address: ________________________________________
Occupation: __________________
☐ Employed ☐ Unemployed ☐ Student ☐ Other
Family Income (per month):
☐ <20,000 PKR ☐ 20,000–40,000 PKR ☐ 40,000–60,000 PKR ☐ >60,000 PKR
Section 2: Oral Hygiene Practices
What cleaning method do you use?
☐ Miswak
☐ Toothbrush
☐ Hands
☐ Other (please specify): _____________
If you use a toothbrush, what type is it? ☐ Soft ☐ Medium ☐ Hard
If you use Miswak, which type do you prefer?
☐ Peelu (Salvadora persica)
☐ Neem (Azadirachta indica)
☐ Zaitoon (Olea europaea)
☐ Kikar (Acacia arabica)
☐ Ban (Glycosmic pentaphylla)
☐ Khiran (Capparis aphylla)
How often do you clean your teeth?
☐ Once daily ☐ Twice daily ☐ More than twice daily
Do you use additional cleaning aids?
☐ Dental floss ☐ Mouthwash ☐ Tongue scraper
How much time do you spend cleaning your teeth?
☐ <2 minutes ☐ 2 minutes ☐ >2 minutes
What time of the day do you usually clean your teeth?
☐ Morning ☐ Night ☐Both
What type of water do you use? ☐ Bore water ☐ Tanker water ☐ Line water ☐
Filtered water
Section 3: Oral Health Status
Do you have a history of systemic diseases? (Check all that apply)
☐ Diabetes ☐ Hypertension ☐ Allergies ☐ TB ☐ Cardiovascular disease
☐ Lung disease ☐ Kidney disease ☐ Hepatitis ☐ HIV/AIDS
Oral health conditions:
Do you experience bad breath? ☐ Yes ☐ No
Do you bleed when you brush your teeth? ☐ Yes ☐ No
Do you have teeth that feel mobile/loose? ☐ Yes ☐ No
Do you experience toothaches commonly? ☐ Yes ☐ No
How many cavities do you have currently?
☐ None ☐ 1–3 ☐ More than 3
Have you had cavities in the past? ☐ Yes ☐ No
Do you currently have oral lesions? ☐ Yes ☐ No
Do you have dental staining? ☐ Yes ☐ No
Do you have enamel fluorosis? ☐ Yes ☐ No
Have you ever experienced dental trauma? ☐ Yes ☐ No
Do you have gingivitis? ☐ Yes ☐ No
Do you have periodontitis? ☐ Yes ☐ No
Do you have gum recession? ☐ Yes ☐ No
Do you have dental plaque? ☐ Yes ☐ No
How would you describe the color and health of your gums?
☐ Pink and healthy ☐ Red and swollen ☐ Bleeding and painful
Excluding your wisdom teeth, do you have any missing teeth? ☐ Yes ☐ No
If you have missing teeth, do you have:
☐ Complete denture ☐ Partial denture ☐ Implant(s) ☐ Fixed bridge work ☐ None of
the above
In general, would you say your oral health (teeth, mouth, and gums) is:
☐ Excellent ☐ Very good ☐ Good ☐ Fair ☐ Poor
Have you felt depressed or sad because of problems with your teeth, mouth, or
dentures? ☐ Yes ☐ No
Have you had difficulty doing your usual jobs because of problems with your teeth,
mouth, or dentures? ☐ Yes ☐ No
Section 4: Dental Visits and Care
How often do you visit a dentist?
☐ Regular check-ups ☐ When experiencing pain ☐ Rarely ☐ Never
What is the purpose of your dental visits?
☐ Cleaning ☐ Treatment for pain ☐ Preventive care ☐ Other: ___________
Why do you not visit dentists frequently for basic procedures?
☐ Too expensive ☐ Dental anxiety ☐ No time ☐ I think my oral health is good
Do you smoke? ☐ Yes ☐ No
What do you think about your oral health? ☐ Very good ☐ Good ☐ Fair ☐ Poor
Consent Acknowledgment
By filling out this survey, I confirm that I voluntarily participated in this study and
provided accurate information to the best of my knowledge.
Signature: _______________________ Date: _________________
