Dental Anxiety Assessment Form
Full Name
Age
Contact Information
How do you feel about visiting the dentist?
Not nervous
Slightly nervous
Fairly nervous
Very nervous
How anxious do you feel prior to a dental appointment?
No anxiety
Mild anxiety
Moderate anxiety
Severe anxiety
What specific dental procedures make you anxious? (Select all that apply)
Cleaning
Filling
Extraction
Root canal
Other
Please describe any previous negative dental experiences
Would you like sedation options to help ease your anxiety?
Yes
No
Any specific concerns or questions?