1. Age
2. Sex	Male
	Female
3. Place of origin
4. How many teeth do you have in your mouth?	>20 teeth
	10–19 teeth
	1–9 teeth
	totally edentulous patient
5. Are you a smoker?	Yes
	No
6. When did you last go to the dentist?	performed within 6 months
	performed within 1 year
	more than a year since the last visit
7. How many times did you brush your teeth in a day before being hospitalized?	times/after meals daily
	times daily
	1 time daily
	Never
8. Did you use interdental brushes?	Yes
	No
9. If yes, how often weekly?	Yes, but it has been treated
	Yes, but I neglect the problem
	No, I wasn’t told
	I don’t know
10. When brushing your teeth, do your gums bleed?	Yes
	No
11. Did you clean your tongue before hospitalization?	Yes
	No
12. Did the dentist ever tell you that you have gum problems, gum infections or inflammation?	Yes, but it has been treated
	Yes, but I neglect the problem
	No, I wasn’t told
	I don’t know
13. Did the dentist extract your teeth because they had high mobility?	Yes
	No
14. Are you wearing a fixed prosthesis?	Yes
15. Are you wearing a removable prosthesis?	Yes, total
	Yes, partial
	Yes, both total and partial
	No
16. Has anyone in your family of origin (father, mother, siblings, uncles, …) had gum problems such as periodontitis?	Yes
	No
	I don’t know
17. Do you suffer from xerostomia (dry mouth)?	Yes
	No
18. Which home oral hygiene aids do you use now that you are hospitalized?	toothbrush + toothpaste + floss
	prosthesis brush + toothpaste + tablets
	toothbrush + toothpaste
	nothing
19. How many times do you brush your teeth a day, now that you are hospitalized?	1230
20. Do you still clean your tongue now?	Yes
	No
21. Do you currently bleed from your gums while cleaning your teeth?	Yes
	No
22. Did you have any chewing problems during the period of illness (COVID-19)?	Yes
	No
23. Did you have any swallowing problems during the period of illness (COVID-19)?	Yes
	No
24. Did you experience a burning sensation in your mouth during the period of your illness (COVID-19)?	Yes
	No
25. Did you experience halitosis during the period of your illness (COVID-19)?	Yes
	No
26. During the period of your illness (COVID-19) did you have tooth problems/pain?	Yes
	No
27. During the period of the disease (COVID-19) did you have any taste alterations?	Yes
	No
28. Did you suffer from xerostomia during the period of your illness (COVID-19)?	Yes
	No
29. Do you suffer from diabetes?	Yes
	No
30. Do you suffer from cardiovascular disease?	Yes
	No
31. Do you suffer from senile dementia?	Yes
	No
32. Did you experience any other oral problems during hospitalization?	Yes
	No