First Name: ______________________

Date of Birth: ____________

Gender: ____________
Nationality: ____________
Address: _________________________________________________________
Marital Status: ____________
Phone Number: ____________
Email Address: ______________
Occupation: ____________
Educational Background: ____________
Social Media Profile: ______________

1. How frequently do you visit the dentist for routine check-ups and cleanings?
___________________________________________________________

2. Are you satisfied with the level of care you receive from your dentist?
____________________________________________________________

3. Have you ever experience any dental anxiety or fear during dental appointments?
____________________________________________________________

4. Do you feel your dentist effectively communicates with you about your dental health
and treatment options?
______________________________________________________________

5. Have you experienced any tooth pain or sensitivity in the past month?
______________________________________________________________

______________________
Patient
(Signature over Printed Name)
First Name: ______________________
Date of Birth: ____________
Gender: ____________
Nationality: ____________
Address: _________________________________________________________
Marital Status: ____________
Phone Number: ____________
Email Address: ______________
Occupation: ____________
Educational Background: ____________
Social Media Profile: ______________

1. How frequently do you visit the dentist for routine check-ups and cleanings?
___________________________________________________________

2. Are you satisfied with the level of care you receive from your dentist?
____________________________________________________________

3. Have you ever experienced any dental anxiety or fear during dental appointments?
____________________________________________________________

4. Do you feel your dentist effectively communicates with you about your dental health
and treatment options?
______________________________________________________________

5. Have you experienced any tooth pain or sensitivity in the past month?
______________________________________________________________

______________________
Patient
(Signature over Printed Name)