PRACTICE ID
DENTIST ALSO PRACTICE AT OTHER CLINICS 1=YES 2= NO
HQ 1.1 PERCENT OF PATIENTS: 1 - 18 YEARS
HQ 1.1 PERCENT OF PATIENTS: 19 - 44 YEARS
HQ 1.1 PERCENT OF PATIENTS: 45 - 64 YEARS
HQ 1.1 PERCENT OF PATIENTS: 65 AND OLDER
HQ 1.2 PCT OF PATIENTS: WHITE, NOT HISPANIC
HQ 1.2 PCT OF PATIENTS: WHITE, HISPANIC
HQ 1.2 PCT OF PATIENTS: BLACK/AA NOT HISPANIC
HQ 1.2 PCT OF PATIENTS: BLACK HISPANIC
HQ 1.2 PCT OF PATIENTS: AMERICAN INDIAN
HQ 1.2 PCT OF PATIENTS: ASIAN/PI
HQ 1.3 PCT OF PTS WITH BY PRIVATE INSURANCE W/SOME-ALL DENTAL
HQ 1.3 PCT OF PTS COVERED BY PUBLIC PROGRAM PAYS SOME-ALL DENTAL
HQ 1.3 PCT OF PTS NO THIRD PARTY-PAY THEIR OWN BILLS
HQ 1.3 PCT OF PTS NO 3RD PARTY - RECEIVES CARE FREE/OR REDUCED FEE
HQ 2.1 NUMBER PATIENTS SEEN PER WEEK
HQ 2.2 DENTISTS IN THE PRACTICE ACCEPTING NEW PATIENTS 1=YES 2= NO
HQ 2.3 BUSYNESS OF PRACTICE DURING THE PAST 12 MONTHS (1-4)
HQ 2.4A DO NOT HAVE SUFFICIENT TIME TO HELP A PATIENT QUIT SMOKING (AGREE 1-5,6)
HQ 2.4B NOT HAD ADEQUATE TRAINING IN SMOKING CESSATION COUNSELING (AGREE 1-5,6)
HQ 2.4C DO NOT PROVIDE CESSATION COUNSELING B/C FOCUS ON OTHER HEALTH ISSUES (AGREE 1-5,6)
HQ 2.4D DO NOT HAVE RESOURCES NEEDED TO HELP A PATIENT QUIT SMOKING (AGREE 1-5,6)
HQ 2.4E DO NOT PROVIDE CESSATION COUNSELING B/C PROVIDED ELSEWHERE (AGREE 1-5,6)
HQ 2.4F DO NOT PROVIDE CESSATION COUNSELING B/C WE HAVE FEW PTS WHO SMOKE (AGREE 1-5,6)
HQ 2.4G BELIEVE SMOKING CESSATION COUNSELING HAS LIMITED EFFECT (AGREE 1-5,6)
HQ 2.4H CANNOT GET REIMBURSED FOR SMOKING CESSATION COUNSELING (AGREE 1-5,6)
HQ 2.4I PRESCRIBING NICOTINE REPLACEMENT RX IS A HIGH PRIORITY (AGREE 1-5,6)
HQ 2.5A HAVE FORMAL CLINICAL GUIDELINE FOR SMOKING CESSATION(1=Y 2=N 3=UNSURE)
HQ 2.5B HAVE PATIENT INTAKE FORMS RE SMOKING STATUS (1=Y 2=N 3=UNSURE)
HQ 2.5C HAVE STICKERS/TAGS APPLIED TO CHARTS OF PTS WHO SMOKE (1=Y 2=N 3=UNSURE)
HQ 2.5D INSTRUCTIONS ON CHARTS GUIDE STAFF THRU STEPS SMOK CESSATION COUNSELING (1=Y 2=N 3=UNSURE)
HQ 2.5E FLOW SHEETS ON PT CHARTS RE DOCUMENTATION SMOK CESSATION COUNSELING (1=Y 2=N 3=UNSURE)
HQ 2.5F HAVE SELF-HELP OR EDUCATIONAL MATERIALS FOR PATIENTS WHO SMOKE (1=Y 2=N 3=UNSURE)
HQ 2.5G HAVE REFERRAL TO 1-800-QUITNOW (1=Y 2=N 3=UNSURE)
HQ 2.5H HAVE REFER MECHANISMS FOR PTS REQ MORE INTENSIVE ASSISTANCE (1=Y 2=N 3=UNSURE)
HQ 3.1 NUMBER OF COMPUTERS WITH INTERNET ACCESS
HQ 3.2A HAVE HIGH-SPEED INTERNET (DSL OR CABLE)
HQ 3.2B HAVE DIAL-UP (REQUIRES USER TO KEY-IN PHONE NUMBER FOR ACCESS)
HQ 3.2C HAVE OTHER TYPE OTHER INTERNET ACCESS
HQ 3.3A USE COMPUTER FOR PATIENT EDUCATION
HQ 3.3B USE COMPUTER FOR EMAIL
HQ 3.3C USE COMPUTER FOR BILLING/CLAIMS
HQ 3.3D USE COMPUTER FOR DECISION SUPPORT SYSTEMS
HQ 3.3E USE COMPUTER FOR ORDERING SUPPLIES
HQ 3.3F USE COMPUTER FOR PERSONAL USE
HQ 3.3G USE COMPUTER FOR SCHEDULING
HQ 3.3H USE COMPUTER FOR DRUG REFERENCE DATABASE
HQ 3.3I USE COMPUTER FOR ELECTRONIC MEDICAL RECORD
HQ 3.4 PAST YR USED EMAIL/ELECTRONIC/SECURE MESSAGING COMMUNICATE W/PT 1=Y 2=N
PERSON COMPLETING SURVEY 1:DENTIST 2:HYGIENIST 3:OTHER
Month survey completed
Year survey completed