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Phobia selftest

This questionnaire is based on research carried out by the World Health Organisation (WHO), the German Association for Dental, Oral and Orthodontic Health (DGZMK) and the Sensitive Dentists GmbH. Your answers remain strictly confidential.

 

1. Basic Questions
Are you embarrassed about your teeth? yes no
Are you ashamed of showing your teeth? yes no
Have you had strong toothaches? yes no
Do you reluctantly go to the dentist? yes no
Do you experience a feeling of fear before the visit to the dentist? yes no
How many days in advance does a visit to the dentists burden you?
(Days)
2. Information about your experiences with dentists in the past
How many dentists have you been visiting?
Have you ever made bad experiences with dentists? yes no
As dental fear patient you have not received extra sensitive treatment? yes no
Have you been mortified by dentists or their employees because of your dental fear? yes no
Have you ever cancelled an appointment because of your dental fear? yes no
Have you ever quit a treatment because of your dental fear? yes no
Have you ever made bad experience with the quality (eg. of prosthesis) of a dentist’s performances? yes no
When was your last completed visit to the dentist? less 12 months
1-3 years ago
3-15 years ago
> 15 years
If you have already visited several dentists and if you answered one of the other questions with “Yes”, it seems that you have not been in the hands of a good dentist who approached your dental fear with sufficient skills.
3. To what extent does your dental fear or phobia influence the quality of your life?
headaches yes no
toothaches yes no
aching jawbones yes no
Does your dental fear directly or indirectly make you reliant on medication? yes no
How often are you thinking about your fear of dental appointments?
on a daily basis
sometimes
I try to supersede my fear		 yes no
yes no
yes no
Does your dental fear negatively affect your professional career? yes no
Does your dental fear negatively affect your leisure time? yes no
Does your dental fear restrict your social life? yes no
Does your relationship or your sex life suffer from your dental fear? yes no
Does your self-esteem suffer from your dental fear? yes no
You do not feel to be taken for serious, if you speak with somebody about your fears? yes no
If you answered multiple questions (2-3) with “Yes”, you should immediately call on a specialist to deal with your dental fear.
4. What bodily reactions do you experience before going to the dentist?
sweating yes no
shivering yes no
breathlessness yes no
sickness yes no
nausea yes no
diarrhoea yes no
tachycardia yes no
insomnia yes no
nervousness yes no
muscle tension yes no
fear of loss of control yes no
If you answered multiple questions (2-3) with “Yes”, the ability to cooperate is considerably restricted. A co-operation with the dentist becomes almost impossible. But as co-operation is a necessary condition, a treatment in general anaesthesia is likely.
5. Hierarchical Fear Questionnaire (HAF)
The following test is a standardised hierarchical fear questionnaire (HAF), which determines the level of your fear just before a dentist appointment (following Jöhren, 1999).
How would you feel if you had a dentist appointment tomorrow?
You are sitting in the waiting room and are about to be called up. How are you feeling?
Imagine you are entering the examination room. There is that typical smell. How does it make you feel.
You are on the examination chair and the dentist is entering the room.
Together, you are looking at the x-ray and talking about what needs to be done.
How do you feel when the dentist announces that s/he is about to remove some plaque?
The dentist explains that you have cavities, and that s/he will start the necessary treatment.
S/he changes the position of the dental chair and prepares the injection needle.
Imagine the sound of the drill. How does it make you feel?
The dentist explains that the cavity is too serious to be treated and that s/he will have to remove the tooth.
A wisdom tooth needs to be removed. You have already received local anaesthetic. The dentist picks us the scalpel. How are you feeling.
6. Are you aware that dental fear is a natural phenomenon?
Are you aware that dental fear is not a disease in terms of the WHO (World Health Organization)? yes no
Are you aware that phobia about dentist appointments is a real disease in terms of the WHO? yes no
Are you aware that about 60-80% of the populations suffer from a feeling of fear before a visit to the dentist? yes no
Are you aware that a good dentist who disposes of the necessary equipment can treat dental fear patients successfully under general anaesthetic? yes no
Are you aware that patients who suffer from phobia about dentist appointments can only be treated successfully by doctors who have a particular qualification and knowledge? ja nein
7. Personal Information
How old are you?
In which country do you live?
In which city do you live?
Here you have the possibility to tell us about your treatment needs:
How did you hear about us?
      internet
      internet search engine
      print media
      television
      recommendation
      others
Please let us know how we can contact you:
Name*: *mandatory field
Address:
Address 2:
Post Code:
City:
eMail*:
Re-enter eMail*:
Phone: (require call back)

 


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