Network administrative region
Q1A. Update med hx 1st visit
Q1B. Update med hx recall visit
Q1C. Update med hx annual visit
Q1D. Update med hx every visit
Q1E. Update med hx other
Q2A. Use tobacco now
Q2B. Use alcohol now
Q2C. Use illicit drugs now
Q2D. Use Rx drug abuse now
Q2E. Hx tobacco or alcohol use
Q2F. Hx drug abuse Tx
Q2G. Hx mental health Tx
Q2H. Hx of/current chronic pain
Q3A. Past 6mo Rec NSAIDS only
Q3B. Past 6mo Rec Acetominophen only
Q3C. Past 6mo Prescribe opioid only
Q3D. Past 6mo Rec NSAIDS/Aceto & Rx opioid
Q3E. Past 6mo Rec Other
Q4. Licensed to prescribe narcotics
Q5A. Past 6 mo, for prior surgery Rx
Q5B. Past 6 mo, for extraction Rx
Q5C. Past 6 mo, for root canal Rx
Q5D. Past 6 mo, for biopsy Rx
Q5E. Past 6 mo, for implant Rx
Q5F. Past 6 mo, for restoration Rx
Q5G. Past 6 mo, sinus lift Rx
Q5H. Past 6 mo, for bone graft Rx
Q5I. Past 6 mo, for TMJ surgery Rx
Q5J. Past 6 mo, for prior other surgery Rx
Q6A. Past 6 mo … Hydrocodone
Q6B. Past 6 mo … Oxycodone
Q6C. Past 6 mo … Codiene products
Q6D. Past 6 mo … Mepenndine products
Q6E. Past 6 mo … Long-acting viz., Oxycotine
Q6F. Past 6 mo … Other
Q7A. PRN Dosing interval
Q7B. Fixed dosage intervals
Q8A. In past 6mo FREQ Rx 1 day supply
Q8B. In past 6mo FREQ Rx 2 day supply
Q8C. In past 6mo FREQ Rx 3 day supply
Q8D. In past 6mo FREQ Rx 4-5 day supply
Q8E. In past 6mo FREQ Rx 6-7 day supply
Q8F. In past 6 mo FREQ Rx > week supply
Q9. Before … how often obtain records
Q10. If not complete info, would
Q11. How common PTs pressure
Q12. If requested, how likely refill opioid
Q12A. Complexity of procedure
Q12B. PT hx with practice
Q12C. Patient demographic
Q12D. Patient self-report of pain
Q12E. Other
Q13. In past6 mo suspect PT have Rx drug abuse prob
Q13A. About how many of your PT
Q14. Have refrained Rx b/c concern
Q15. How confident able recognize
Q16A. Have not suspected any drug abuse
Q16B. No action evenif suspect
Q16C. Document concerns
Q16D. Confront PT
Q16E. Counse PT
Q16F. Offer educ materials
Q16G. Contact PT family
Q16H. Require urine test
Q16I. Create drug contract
Q16J. Provide Rx no refills
Q16K. Rx non-opiod analgesic
Q16L. Consult another dentist
Q16M. Discharge PT from practice
Q16N. Refer PT to substance abuse Tx
Q16O. Contact police
Q16P. Other
Q17. FREQ explain risks when 1st Rx op
Q18. FREQ discuss side effect Rx op
Q19. FREQ discuss secure storage
Q20. FREQ discuss disposal
Q21. FREQ discuss risks
Q22A. PT already know
Q22B. Not enough time
Q22C. PT will not understand
Q22D. PT will not pay attention
Q22E. Info will scare PT
Q22F. Not my responsibility
Q22G. Not needed for short-term Rx
Q22H. Did not know Rx opioid had risks
Q22I. Uncomfortable discuss risks w/ PT
Q22J. Rely on pharmacist to review risks
Q22K. Would not know what to do if ID abuser
Q22L. PT would not return to my practice
Q23. Ever access state Rx Monitor Program
Q24A. FREQ use PDMP before any Rx opioid
Q24B. FREQ use PDMP before Rx high risk
Q24C. FREQ use PDMP prior initial Rx new PT
Q24D. FREQ use PDMP prior refills
Q25. How helpful was PDMP
Q26. In general PDMP led me to …
Q27A. Did not know it existed
Q27B. Do not know how to access
Q27C. Too timeconsuming
Q27D. Dont know how to discuss w/ PT
Q27E. Info would not have an impact
Q27F. Question timeliness/accuracy data
Q27G. Other
Q28. How well think PDMP could prevent abuse
Q29. How much PDMP risks PT confidentiality
Q30. How big problm Rx opioid is your practice
Q31. Rate your knowledge re risks
Q32. Any training in pain management
Q32A. How much training pain management
Q32B. When rec train pain manage:Dental school
Q32B. When rec train pain manage:Residency
Q32B. When rec train pain manage:Specialty train
Q32B. When rec train pain manage:Continuing ed
Q33. Any training re ID drug abuse/addiction
Q33A. How training re ID drug abuse/addiction
Q33B. When rec train ID drug abuse:Dental school
Q33B. When rec train ID drug abuse:Residency
Q33B. When rec train ID drug abuse:Specialty train
Q33B. When rec train ID drug abuse:Continue Ed
Q34. Any train re ID Rx drug diversion
Q34A. How much train re ID Rx drug diversion
Q34B. When rec train re ID Rx drug diver:Dental school
Q34B. When rec train re ID Rx drug diver:Residency
Q34B. When rec train re ID Rx drug diver:Specialty train
Q34B. When rec train re ID Rx drug diver:Continue Ed
Q35A. How valuable re opioid RX:Pharm course
Q35B. How valuable re opioid RX:Intern/Resid/Fellow
Q35C. How valuable re opioid RX:Work experience
Q35D. How valuable re opioid RX:Journal articles
Q35E. How valuable re opioid RX:Reference books
Q35F. How valuable re opioid RX:Contine Educ
Q35G. How valuable re opioid RX:Drug product manufac
Q35H. How valuable re opioid RX:Colleagues
Q35I. How valuable re opioid RX:Internet
Q36A. Interest rec educ/train:Rx drug abuse/addict
Q36B. Interest rec educ/train:Drug diversion
Q36C. Interest rec educ/train:Rx drug monitor program
Q37. Perc adeq educ/train rec prevent mis/abuse Rx meds
Q38. Clarity laws re your actions should be
Q39. How prepared re assess for Rx drug abuse in PTs
Q40. Worry re review your Rx by regulatory agencies
Q41. Did you Network Quick Poll re Opioid analgesics
Q42. Has reschedule of hydrocone altered your Rx habits
Q43. Aware of CDC Guidelines re Rx opioids,2016
Q44. Have read CDC Guidelines re Rx opioids,2016
EQ GENDER 1-Male, 2-Female
EQ Hispanic 1-Yes, 2-No
EQ 1-General 2-Specialist
EQ Decade dentist graduated 1:<1970,... 5:2000+
EQ Race 1-white, 2-black, 4-Asian, 6-multi/other