Dental Anxiety Program
About You
Name:
DOB:
Date of Visit:
Reason:
Anxiety Level
Rate your anxiety (1-10):
Triggers
Needles
Sounds
Smells
Gag Reflex
Loss of Control
Comfort Preferences
Communication Style
Select...
Full updates
Minimal talking
Hand signals
Sedation Options
Select...
None
Nitrous Oxide
Oral Sedative
IV Sedation
Extra Notes
Submit