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Mount Sinai Dental Fear Inventory
Please fill out all these forms before your first visit:
☐
Medical History Form
☐
Patient Account Information
☐
Appointment Preference Form
☐
Corah's Dental Anxiety Scale
☐
Mount Sinai Dental Fear Inventory
First Name
Last Name
Home Phone
Work Phone
Email
On a scale of 1 to 100
, where
1
is so relaxed you could fall asleep, and
100
is the point where you are about to faint or become sick, please rate the following situations.
0
10
20
30
40
50
60
70
80
90
100
Sitting in the dentist's waiting room
0
10
20
30
40
50
60
70
80
90
100
Smelling the "smell" of a dentist's office
0
10
20
30
40
50
60
70
80
90
100
Sitting up in a dental chair
0
10
20
30
40
50
60
70
80
90
100
Reclining in a dentist chair
0
10
20
30
40
50
60
70
80
90
100
Seeing the needle and syringe for anesthesia
0
10
20
30
40
50
60
70
80
90
100
Receiving the anesthetic injection
0
10
20
30
40
50
60
70
80
90
100
Hearing the noise of the dentist drill
0
10
20
30
40
50
60
70
80
90
100
Having a tooth drilled
0
10
20
30
40
50
60
70
80
90
100
Seeing the dental probes or instruments
0
10
20
30
40
50
60
70
80
90
100
Having the dental instruments manipulated in your mouth
0
10
20
30
40
50
60
70
80
90
100
The dentist walks into the treatment room
0
10
20
30
40
50
60
70
80
90
100
Having your teeth cleaned
0
10
20
30
40
50
60
70
80
90
100
Having dental x-rays taken
0
10
20
30
40
50
60
70
80
90
100
If you answered more than 50 for any question, then you have some serious fears that should be addressed.
0-50 - average levels of fear or concern
50-80 - high levels of fear
80-100 - extreme level of fear
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