Patient name

E-mail address

I have a strong gag reflex.
Yes No

Lying in the dental chair makes me feel out of control.
Yes No

I am nervous that I'll be judged because I have not visited a dentist in a long time.
Yes No

My main concern is pain control
Yes No

Injections make me nervous.
Yes No

I have a bad physical reaction to dental injections.
Yes No

My teeth are sensitive.
Yes No

The dental hook that probes for cavities makes me nervous.
Yes No

I don't like the sounds of dental tools.
Yes No

Please don't use cotton in my mouth.
Yes No

I don't know much about dental care, so I need education and instruction.
Yes No

My time is very limited, so please don't make me wait.
Yes No

Please tell me what to expect financially; I do not like surprises.
Yes No

I will forget what you tell me while I am in the dental chair.
Yes No

I have special health concerns ( diabetes, medications, etc.)
Yes No

Other Concerns:.