Dental Anxiety Scale Questionnaire
Please complete this form to help us assess your level of dental anxiety. Your responses are confidential and will assist in providing better care.
Full Name
*
First Name
Last Name
Age
*
Gender
Male
Female
Other
Prefer not to say
Email Address
example@example.com
How anxious do you feel about visiting the dentist?
*
Not at all anxious
1
2
3
4
5
6
7
8
9
Extremely anxious
10
1 is Not at all anxious, 10 is Extremely anxious
If you had to go to the dentist tomorrow, how would you feel?
*
Relaxed
A little uneasy
Tense
Anxious
Very anxious
How do you feel while waiting in the dentist's office for your turn?
*
Calm
A little nervous
Tense
Anxious
Very anxious
How do you feel about having your teeth cleaned?
*
No problem
Slightly uneasy
Uncomfortable
Anxious
Very anxious
How do you feel about having a tooth drilled?
*
No problem
Slightly uneasy
Uncomfortable
Anxious
Very anxious
How do you feel about receiving a local anesthetic injection in your gum?
*
No problem
Slightly uneasy
Uncomfortable
Anxious
Very anxious
Please share any additional comments or experiences regarding dental anxiety.
Submit
Should be Empty: