Patient # _______

The gag reflex is a contraction of the muscles of the pharyngeal sphincter (upper oesophagus or throat). The gag reflex is a natural protective measure of the body to protect an airway from blocking and remove material from the throat and upper gastrointestinal tract (Fiske & Dickinson, 2001). Although the gag reflex typically serves this protective function, a strong gag reflex may impact daily life.

For the following questions, please use the scale of 1-7, in which 1 is the least severe and 7 is the most.

  1. Do you have a gag reflex? YES/NO
  2. How strong would you say your gag reflex is? Please circle the corresponding number on the following scale.

1 2 3 4 5 6 7

Not strong at all-----------moderately strong---------------very strong

  1. Have you ever had a negative incident with gagging? YES/NO
  2. Have you ever gagged at a dentist/orthodontist office before? YES/NO
  3. Please circle any of the following experiences that have caused you to gag:

Routing teeth-cleaning Root canal

Cavity filling Dental impression

Dental x-ray Other orthodontic work

Other dental work

  1. When you are going to the dentist, how much stress (if any) do you experience that is related to your gag reflex? Please circle the corresponding number on the following scale.

1 2 3 4 5 6 7

none -----------somewhat-------------much------------a great deal

7. Have daily activities, like brushing or flossing your teeth, ever made you gag? YES/NO

How often are these occurrences?

1 2 3 4 5 6 7

never -------------seldom------------sometimes------------often

  1. Do you ever worry that daily activities other than brushing or flossing your teeth will cause you to gag? YES/NO
  2. Does coughing ever cause you to gag? YES/NO
  3. Have you ever gagged while trying to swallow pills? YES/NO

Survey Scoring

1. yes = 1, no = 0

2. 1-2 = 0, 3-5 = 1, 6-7 = 2

3. yes = 1, no = 0

4. yes = 1, no = 0

5. 1 point for each item circled

6. 1-2 = 0, 3-5 = 1, 6-7 = 2

7. yes = 1, no = 0 / 1-2 = 0, 3-5 = 1, 6-7 = 2

8. yes = 1, no = 0

9. yes = 1, no = 0

10. yes = 1, no = 0