2. Environment:
There are a variety of possible triggers in the surgery itself. Please tick any or many that you have had or still have.
a) clinical smells
b) people in a hurry
c)stressed or busy staff
d) dental instruments
e) noise of instruments
f) the dental chair or lying down

Other – please add.

3. Information:
At times you need information but don’t have it and are afraid to ask. Why is this?
a) you don’t know what to ask about
b) someone might think you silly
c) unhelpful staff
d) feeling out of control

Other – please add.

4. Treatment:
Which of the following makes you fearful? Please tick any or many fears that you have had or still have.
a) staff talking above you, not to you
b) not knowing what’s going on
c) the condition of your teeth
d) being told off
e) painful work to be done
f) injections and needles
g) inclined position of the dental chair
h) gagging or choking
i) the dentist not having sympathy with fears
j) the dentist not being kind
k) a long appointment
l) not knowing when I can swallow
m) no calming and helpful advice given
n) is the treatment really necessary
o) opening my mouth and people touching it
p) having a panic attack in the mvaluedle of treatment
q) needing lots of appointments
r) no escape
s) x-rays
t) being left with my mouth open
u) not given choices of treatment
v) allergies to materials used
w) rough use of instruments
x) scary looking staff
y) having my mouth stretched too much

Other – please add.

5. Your view of causes: please complete this
To expand on question 1, can you list who, or what you believe helped to cause your dental phobia in the box below. e.g. if you think that : 1.a) was a cause, also state who, if you know. For all other sections please state if anyone passed on any other possible fears, in some way, numbering in the same way; 3.d) etc.

Thank you for your time. If there is anything else you want to add please add here. Perhaps this questionnaire is too short? Many thanks for your help in this. Julia Croft

Please fill in the fields below. All personal information is confidential and only used to assist my understanding when in the consulting room. Figures only will be used to collate the information, in order to see any relevant trends. Your contact details are required in order that I can reward you with the free relaxation track – MP3 or CD (please state which).

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