Mentor, OH

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Dental Anxiety Questionnaire

Please print the following test and bring it with you to your dental appointment.

Norman Corah's Dental Questionnaire (DAS-R)

1. If you had to go to the dentist tomorrow for a check-up, how would you feel about it?

     a. I would look forward to it as a reasonably enjoyable experience.
     b. I wouldn't care one way or the other.
     c. I would be a little uneasy about it.
     d. I would be afraid that it would be unpleasant and painful.
     e. I would be very frightened of what the dentist would do.

2. When you are waiting in the dentist's office for your turn in the chair, how do you feel?
     a. Relaxed.
     b. A little uneasy.
     c. Tense.
     d. Anxious.
     e. So anxious that I sometimes break out in a sweat or almost feel
         physically sick.
3. When you are in the dentist's chair waiting while the dentist gets the drill ready to begin working on your teeth, how do you feel?
     a. Relaxed.
     b. A little uneasy.
     c. Tense.
     d. Anxious.
     e. So anxious that I sometimes break out in a sweat or almost feel
        physically sick.
4. Imagine you are in the dentist's chair to have your teeth cleaned. While you are waiting and the dentist or hygienist is getting out the instruments which will be used to scrape your teeth around the gums, how do you feel?
     a. Relaxed.
     b. A little uneasy.
     c. Tense.
     d. Anxious.
     e. So anxious that I sometimes break out in a sweat or almost feel
         physically sick.


DENTAL CONCERNS ASSESSMENT*
Please rank your concerns or anxiety over the dental procedures listed below by ranking them on the accompanying scale. Please fill in any additional concerns.

Please rank your level of Concern or Anxiety
Low-1    Moderate-2   High-3    Don't know-4

1. Sound or vibration of the drill
2. Not being numb enough
3. Dislike the numb feeling
4. Injection ("novocaine")
5. Probing to assess gum disease
6. The sound or feel of scraping during teeth cleaning
7. Gagging, for example during impressions of the mouth
8. X-rays
9. Rubber dam
10. Jaw gets tired
11. Cold air hurts teeth
12. Not enough information about procedures
13. Root canal treatment
14. Extraction
15. Fear of being injured
16. Panic attacks
17. Not being able to stop the dentist
18. Not feeling free to ask questions
19. Not being listened to or taken seriously
20. Being criticized, put down, or lectured to
21. Smells in the dental office
22. I am worried that I may need a lot of dental treatment
23. I am worried about the cost of the dental treatment I may need
24. I am worried about the number of appointments and the time that will be required for necessary appointment and treatment; time away from work, or the need for childcare or transportation
25. I am embarrassed about the condition of my mouth
26. I don't like feeling confined or not in control
27. Other concern not mentioned

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Fioritto Family Dental