Patient Questionnaire

Can you tell me how anxious you get, if at all, with your dental visit by answering these 5 questions.

There are no right or wrong answers, just how you feel.

Name

First Name

Last Name

Your Dental Practice

(###)

###

####

1. If you went to your Dentist for TREATMENT TOMORROW, how would you feel?

2. If you were sitting in the WAITING ROOM (waiting for treatment), how would you feel?

3. If you were about to have a TOOTH DRILLED, how would you feel?

4. If you were about to have your TEETH SCALED AND POLISHED, how would you feel?

5. If you were about to have a LOCAL ANAESTHETIC INJECTION in your gum, above an upper back tooth, how would you feel?

If you would like to tell me more detail on your feelings about dentistry please do so in this box.

Thank you for your answers.

Magenta Sedation