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Anxiety Level Assessment


To help assess your Dental Anxiety Level, please answer the following questions and your results will be
emailed to the address you provide. The answers to these questions will determine how we can best treat
you and what type of anesthesia would be most beneficial for you.

1.) Do you feel slight uneasiness and tension the evening prior to your dental visit, which makes you consider canceling your dental appointment?

2.) While waiting in the reception area of the dental office, do you feel nervous about the visit?

3.) Have you had a prior dental experience that was unpleasant?

4.) While in the dental chair, do you feel uneasy and anxious?

5.) Does the thought of having a dental injection make you feel physically ill and tense?

6.) Does seeing the dentist or dental hygienist's instruments make you anxious?

7.) Do you feel embarrassed that the dentist will say you have the worst mouth they have ever seen?

8.) Do objects placed in your mouth during the dental visit make you panic and feel like you cannot breathe correctly?

9.) Do you feel that your dentist is unsympathetic with you?

10.) Have you ever tolerated your dental pain just to avoid a visit to the dentist?

11.) Do you feel dentists are efficient, but often seem they're in a hurry?

12.) Do you feel that dentists will do what he/she wants to do no matter what you say?

13.) Do you feel that dental professionals say things to make you feel guilty about the way you care for your teeth?

14.) Do you think you can believe what the dentist says about the work that is needed?

15.) Do you feel that dentists do not take your worries (fears) seriously?

16.) Do you worry about the dentist's infection control methods?

17.) Do you feel that if you were to indicate that a treatment hurts, that the dentist would stop and try to correct the problem?

18.) Do you feel that when you're in the chair that the treatment can't be interrupted, if you need a moment to rest?

19.) Do you feel that dentists do not like it when you make a request?

20.) Do you feel that dentists do not really listen to what you say?

Please enter your name or the name of the person to contact:

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