Florida New Member Survey Please fill out this form so we can help provide you with the best care. Complete one form for each member of your household who is a DentaQuest Plan member. Member Information First Name: Last Name: Date of Birth: Phone: DentaQuest Member ID Number: Your DentaQuest Member ID number is the 9- or 10-digit number on the front of your card. New Member Survey Do you have tooth pain or a dental problem right now?: YesNo Have you been to the Emergency Room for a dental problem in the past 12 months?: YesNo Was your last visit to the dentist more than 12 months ago?: YesNo Do you brush your teeth less than twice a day?: YesNo Do you have a special need that makes it hard to see the dentist?: YesNo If yes, which one? (Select all that apply): I have an intellectual and/or physical disabilityI am nervous or afraid to visit the dentistI use a wheelchair or stretcherOther (please explain) Explanation: Are you pregnant?: YesNo Do you have a health problem or illness that makes it hard for you to see the dentist?: YesNo If yes, which one? (Select all that apply): DiabetesKidney diseaseLung diseaseCancerMental illness or mental health problemDrug or alcohol use or abuseOther (please explain) Explanation: Do you have any other type of problem that makes it hard for you to see the dentist? (For example, "I don't have a way to get to the dentist."): YesNo Explanation: