Dental Anxiety Assessment Form
Name
Email
How do you feel about visiting the dentist?
Calm
A little nervous
Anxious
Very anxious
Have you ever delayed or avoided dental treatment due to fear or anxiety?
Yes
No
What specific aspects of dental visits make you anxious? (e.g., needles, pain, sounds, etc.)
How anxious do you feel before a dental appointment?
Not at all
Slightly anxious
Moderately anxious
Very anxious
Have you found any strategies that help you cope with dental anxiety?
Anything else you would like the dental team to know?