Home 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 Please rate the following situations 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. 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 dental 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's 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 Seeing the dentist walk 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, you have some serious fears that should be addressed. 0-50 - average level of fear or concern 50-80 - high level of fear 80-100 - extreme level of fear This site and contents ©2008 Michael Krochak, DMD All Rights Reserved Our Philosophy of Care Restorative Dentistry Cosmetic Dentistry Our People Dental Technology Services and Amenities Appointments Emergencies Fees and Insurance Processing Share a Smile