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Dental Patient Form
This dental patient form is designed to take the guesswork out of patient anxieties. It also reassures patients that you are aware of patient anxieties.
Used as an adjunct to the medical history questionnaire, it allows you to address fears quickly and efficiently, and to foresee potential problems. Nothing worse than having a patient panic in the middle of a procedure...
The form is based on Mac Lee, DDS's "Please Handle Me with Care" form (in "I hate dentists"). This original version can be found on various dental websites, for example Today's Dentistry. The modified version below was created with the input from nervous patients.
"Please Handle Me With Care" Patient Form
Please circle the number next to the statements that concern you or describe your situation.
- I have not been to the dentist for a long time, and I feel worried about what you will say about my teeth and my oral hygiene.
- My teeth are very sensitive.
- Pain relief is a top priority for me.
- I'm very anxious about injections.
- I feel out of control in the dental chair (or I have an extreme problem with lying down).
- I gag easily.
- I hate the noise of dental instruments.
- Please tell me about the treatment options and the ways these can be carried out.
- I need to know that you will stop when I give a pre-agreed "stop" signal during treatment.
- It would help me if you could explain to me what you are doing and why.
- I have health problems that we need to discuss.
- There are other issues I'd like to talk about that aren't covered on this form.
"Please Handle Me With Care" PDF download
Feel free to use this questionnaire or modify it according to your needs.
Many thanks to Mac Lee for allowing us to use and modify this patient form.