Objectives: The purpose of this study was to develop a self-administered questionnaire survey to de-termine its validity and reliability as well as to improve the instructions for measurement of periodontal disease during oral examination for reliably calculating the prevalence of periodontal disease.Methods: The data obtained was analyzed using SPSS 20.0 and the WINSTEPS program that employs the Rasch model to evaluate validity and reliability of the instrument.Results: We developed a self-administered questionnaire survey consisting of 14 questions based on NHANES. We confirmed the reliability by testing and re-testing the questionnaire survey using self-administered methods. The average Kappa index obtained was 0.73, which indicated a relatively high reliability.Conclusions: Reliability and validity of the self-administered assessment tool for periodontal disease developed for the local situation/circumstances of Korea is suitable to be applied for oral examination of a large population. Moreover, the questionnaire survey for periodontal disease could be used to acquire data for constructing a database for oral health policy development.