Dental anxiety questionnaire sheet

How much anxiety/fear or discomfort does each of these causes you? Please use the numbers from the scale for the first three questions 1) None at all 2) A little 3) Somewhat 4) Much 5) Very much

2) Being seated in dental chair

3) All things considered, how fearful are you of having dental work done

4) If you had to go to the dentist tomorrow, how would you feel about it?

a) I will look forward to it as a reasonably enjoyable experience.

b) I would not care one way or another.

c) I would be a little uneasy about it.

d) I would be afraid that it would be unpleasant and painful.

e) I would be very frightened of what the dentist might do.

5) When you are waiting in the dentist office for your turn in the chair, how do you feel

a) Relaxed

b) A little uneasy

c) Tense

d) Anxious

e) So anxious that I sometime break out in sweat or almost feel physically sick

6) When you are in the dentist’s chair while she gets the drill ready to begin working on your teeth how do you feel?

a) Relaxed

b) A little uneasy

c) Tense

d) Anxious

f) So anxious that I sometime break out in sweat or almost feel physically sick

Please rank your concern or anxiety over the dental procedures listed below by ranking them from the scale 1. Low 2. Moderate 3. High 4. Don’t know

7) Sound or vibration of the drill

8) Not being numb enough

9) Dislike the numb feeling

10) Injection

11) Extraction

12) Fear of being injured

Question 1 and 2 originate from the DFS, question 3 through 5 originate from Corah’s DAS and question from 6 through 11 are from Clark’s Dental Concerns Assessment