Anxiety Level Assessment

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

      Yes
      No

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

      Yes
      No

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

      Yes
      No

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

      Yes
      No

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

      Yes
      No

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

      Yes
      No

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

      Yes
      No

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

      Yes
      No

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

      Yes
      No

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

      Yes
      No

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

      Yes
      No

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

      Yes
      No

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

      Yes
      No

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

      Yes
      No

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

      Yes
      No

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

      Yes
      No

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?

      Yes
      No

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?

      Yes
      No

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

      Yes
      No

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

      Yes
      No

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