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 and 2011 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 Drs. Krochak/Perlman