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?

- Choose One - Yes No

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

- Choose One - Yes No

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

- Choose One - Yes No

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

- Choose One - Yes No

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

- Choose One - Yes No

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

- Choose One - Yes No

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

- Choose One - Yes No

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

- Choose One - Yes No

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

- Choose One - Yes No

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

- Choose One - Yes No

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

- Choose One - Yes No

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

- Choose One - Yes No

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

- Choose One - Yes No

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

- Choose One - Yes No

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

- Choose One - Yes No

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

- Choose One - 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?

- Choose One - 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?

- Choose One - Yes No

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

- Choose One - Yes No

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

- Choose One - Yes No

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