Dental Anxiety Assessment

Your answers to the following questions are required so your dentist can refer you for dental treatment with sedation:

If you went to your dentist for TREATMENT TOMORROW, how would you feel?
Not anxiousSlightly anxiousFairly anxiousVery anxiousExtremely anxious

If you were sitting in the WAITING ROOM (waiting for treatment) how would you feel?
Not anxiousSlightly anxiousFairly anxiousVery anxiousExtremely anxious

If you were about to have a TOOTH DRILLED, how would you feel?
Not anxiousSlightly anxiousFairly anxiousVery anxiousExtremely anxious

If you were about to have your TEETH SCALED AND POLISHED, how would you feel?
Not anxiousSlightly anxiousFairly anxiousVery anxiousExtremely anxious

If you were about to have a LOCAL ANAESTHETIC INJECTION in your gum, above an upper back tooth, how would you feel?
Not anxiousSlightly anxiousFairly anxiousVery anxiousExtremely anxious

Please confirm your name and date of birth:
Full name:
Date of birth: