Dental anxiety questionnaire form

Please take a few moments to answer the following questions which will allow the dental team to provide the care and advice based on your concerns and individual needs. Your answers are for our records only and will be treated as confidential.

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Your details

Name Telephone Email is required How would you feel if you had a dentist appointment tomorrow? You are sitting in the waiting room and are about to be called up. How are you feeling? Imagine you are entering the examination room. How does it make you feel? You are on the examination chair and the dentist is entering the room. How does it make you feel? Together, you are looking at the x-ray and talking about what needs to be done. How does it make you feel? How do you feel when the dentist announces that they are about to remove some plaque? The dentist explains that you have cavities, and that they will start the necessary treatment. How does it make you feel? They change the position of the dental chair and prepare the injection needle. How does it make you feel? Any additional comments

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