The document is a modified dental anxiety scale questionnaire. It contains 5 questions that ask patients to rate their level of anxiety for different dental procedures such as treatment, waiting, drilling, scaling, and local anesthetic injections. Patients indicate their anxiety level by selecting one of 5 options ranging from "not anxious" to "extremely anxious." The questions are scored from 1 to 5 and added up, with a total score of 19 or higher indicating a highly dentally anxious or possibly dentally phobic patient.