Dental Anxiety Evaluation Form
Full Name
Age
Email Address
How do you feel about visiting the dentist?
Calm
Slightly anxious
Very anxious
Terrified
Have you ever postponed a dental appointment due to anxiety?
Yes
No
What aspect of dental visits causes you the most anxiety?
Pain or discomfort
Injections/Needles
Sounds of dental equipment
Feeling of lack of control
Other
If you have any specific concerns or suggestions, please write them below: