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Please print and complete the following:
WhatFear.com Dental Anxiety Questionnaire (WFDAQ).
1) Sex: Male [ ] Female [ ] 2) Age: [ ] years 3) How long has it been since your last dental visit? .. .. 4) What is your longest period of time between visits? 5) Have you ever missed or cancelled, or avoided making a dental appointment due to anxiety or fear? YES [ ]NO [ ] 6) On a scale of 0 to 10, 10 being the most pain you can imagine, how painful have you found previous dental treatment? 0 1 2 3 4 5 6 7 8 9 10 7) On a scale of 0 to 10, 10 being the most pain you can imagine, how painful do you anticipate future dental treatment to be? 0 1 2 3 4 5 6 7 8 9 10 8) Do you have any family or close friends who are anxious or fearful of dental treatment? YES [ ] NO [ ] If yes, please specify ................. 9) Do you have any other anxieties or fears? YES [ ] NO [ ] If yes, please specify
10) Do you feel that you have a low tolerance to discomfort or pain in general? YES [ ] NO [ ] If yes, please specify 11) Do you worry about treatment because you are unsure about what is involved? YES [ ] NO [ ] 12) Are you worried that the local anaesthetic may not work and the dentist will carry out a procedure when your tooth is not numb/ asleep / frozen. YES [ ] NO [ ] 13) Are you afraid that you may gag or choke during treatment? YES [ ] NO [ ] 14) Have you ever had a bad experience at the dentist which makes you worried about future visits? YES [ ] NO [ ] If yes, please specify .......................................... .
15) Do you worry that you may come to great harm, or have a serious medical emergency while having dental treatment? YES [ ] NO [ ] If yes, please specify ....................................
16) If you had to go to the Dentist tomorrow, how would you feel? a) I would look forward to it as a reasonably enjoyable experience[ ] b) I wouldnt 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 might do. [ ]
17) When you are waiting in the Dentists waiting room for your turn in the chair, how do you feel? a) Relaxed [ ] b) A little uneasy [ ] c) Tense [ ] d) Anxious [ ] e) So anxious I sometimes break out in a sweat or almost feel physically sick. [ ]
18) When you are in the Dentists chair waiting while the Dentist is probing and examining your teeth, how do you feel? a) Relaxed [ ] b) A little uneasy [ ] c) Tense [ ] d) Anxious [ ] e) So anxious I sometimes break out in a sweat or almost feel physically sick. [ ]
19) When you are in the Dentists chair waiting while he prepares the needle syringe for your injection, how do you feel? a) Relaxed [ ] b) A little uneasy [ ] c) Tense [ ] d) Anxious [ ] e) So anxious I sometimes break out in a sweat or almost feel physically sick. [ ]
20) When you are in the Dentists chair waiting while he gets his 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 I sometimes break out in a sweat or almost feel physically sick. [ ]
21) When you are seated in the Dentists chair to have a scale and polish and the Dentist is getting out the instruments to use on your teeth and gums, how do you feel? a) Relaxed [ ] b) A little uneasy [ ] c) Tense [ ] d) Anxious [ ] e) So anxious I sometimes break out in a sweat or almost feel physically sick. [ ]
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Click here for a key which will explain some of the possible reasons for your fear of the dentist |
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