Your Dental Experience
Thank you so much for being willing to be open and candid with me. I know I've already used "the D word" and made you cringe (I'm sorry!) and I apologize in advance for how twitchy and uncomfortable some of these questions may prove to be for you. My suggestion? Have some tissues, a cup of something warm, and maybe a pet nearby as you fill this out.

Your answers are acting as research for a book I'm writing about the fears surrounding dental work, though I promise to be as discrete as you prefer. Please do not hesitate to use a fake name on this form, and feel zero pressure in providing an email if the idea makes you uncomfortable. Know that I share this fear with you and respect how difficult this is, and I am endlessly grateful for your participation. If, however, you do provide a form of contact and this book becomes a reality, I'd love to reach out to you at a later date so that I can share it with you!

Just answer each of the questions to the best of your ability, be as candid as you are able, and remember that there are no wrong answers. If you have any questions for me or have anything else to share, please reach out via email at THANK YOU, from my whole heart.

xx, Jenn
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Your Name (this may be used in my writing so please feel free to use a fake name here - anything you like!) *
Your current age (A range is also okay if you prefer not to say could say early 20's, mid-30's, late teens, for example.) *
While gender is not particularly important in fear, I'm curious about the treatment of boys vs girls in early dental care. Would you mind sharing with me which gender you identify as? *
Would you share your general location with me? Doesn't have to be specific...even just state is fine! *
How would you describe your level of fear in regards to the dentist and dental work? *
At what age would you say your fear began? (Enter 0 if you have no particular fears.) *
What would you say was the MAIN cause of your original fear? (You'll be able to choose other factors in just a moment!) *
What would you say are the contributing factors to your ongoing fear, or your previous fear if you've since overcome it? *
When was the last time you received any form of dental care? (Anything counts - a cleaning, exam, filling, root canal, braces, etc.) *
Do you currently have a doctor that you would call "your" dentist? *
What would you say holds you back from looking for a new dentist? *
What factors would you say would help comfort you or ease your fear during your visits? *
What would you say would be the MOST impactful factor from the checklist above? Try to pick just one! *
If your dental care is lapsed or ever has been, what would you say would bring you back to receiving care (or what DID bring you back)? *
Do you talk about your fear with anyone? *
How do you feel about the overall state of your teeth? *
Playing the "blame game" is never a great tactic, but if you really ask yourself - who do you hold responsible for the development of your fear or bad experiences? *
How common do YOU think a fear of the dentist and dental work is? *
Do you feel judged when it comes to dental work? *
Would you say that you have general anxiety or other types of anxiety in your life unrelated to dental work? *
What emotions and feelings would you say you feel when your fear is triggered? *
What is your biggest worry concerning the effects of your fear? *
If you've tried any of the following to help you with your fear and you feel that they've worked, please check them! *
Are you willing to share more of your story or answer any questions I may have for you in the future? *
If you answered yes to the above and/or you want to be contacted when I finish this book, please provide an email address where I can contact you!
Now - here is your chance to tell me everything! I want to know your story! What happened in your past? What helped develop your fear? What specific struggles did you encounter? Have you overcome it or have a success story? Any tips or pointers to offer others that share your fear? Do you not have any fear at all and want to share what you attribute with your success concerning dental work? Tell me everything! Feel free to change names, locations, and even specific details to help remain anonymous.
If you could leave one (or a few) tips, lines of encouragement, or suggestions for someone struggling with a fear of dental work, what would it/they be?
This is your disclaimer! I understand that all of the information provided here can and may be used in the writing and potential publication of a book with full permission on my part. If I prefer to have my name changed (other than the one I provided here) or any other specific details, I will send an email requesting such to prior to 6/1/2020. *
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