Name:
eMail:
Home Phone:
Work Phone:


On a scale of 0 to 100, where 0 is so relaxed you could fall asleep, and 100 is the point when you are so fearful you might faint, become sick or run out of the treatment room, please rate the following situations.
  1. Sitting in the dentist’s waiting room =

  2. Smelling the "smell" of a dentist’s office =

  3. Sitting up in a dental chair =

  4. Reclining in a dental chair =

  5. Seeing the needle and syringe for anesthesia =

  6. Receiving the anesthetic injection =

  7. Hearing the noise of the dentist’s drill =

  8. Having a tooth drilled. =

  9. Seeing the dental probes or instruments. =

  10. Having the dental instruments manipulated in your mouth. =

  11. The dentist walks into the treatment room. =

  12. Having your teeth cleaned. =

  13. Having dental x-rays taken. =

  14. Other (please specify below) =

If you would rather mail us this form, simply fill out each field and then print this page by selecting the Print option on your File menu otions above. Then mail this form to the address below:

    29 WEST DENTAL ASSOCIATES
    29 West 57th Street, 6th Floor
    New York, N.Y. 10019
    Ph (212) 838-2900
    Fax (212) 935-4703