Patient Questionnaire

Your smile affects your self-image, and can greatly influence the quality of your interactions with others. Many people hold back from laughing or smiling because they are uncomfortable with their smile. The following questions are designed to honestly appraise your smile. Go to a mirror, smile as wide as you can, and ask yourself the following questions:

Are any of your teeth yellow, stained or somewhat discolored?
YesNo

Would you like your teeth to be whiter?
YesNo

Do you have any gaps or spaces between your teeth?
YesNo

Are any of your teeth turned, crooked, or uneven?
YesNo

Are you missing any teeth?
YesNo

Do you see any pitting or defects on the surfaces of your teeth?
YesNo

Are the edges of any teeth worn down, chipped or uneven?
YesNo

Do any of your teeth appear too small, short, large or long?
YesNo

Do you have any prior dental work that appears unnatural?
YesNo

Do you have any crowns or bridges that appear dark at the edge of your gums?
YesNo

Do you have any gray, black or silver (mercury) fillings in your teeth?
YesNo

Do you have a "gummy" smile (too much of your gums show when smiling)?
YesNo

Are your gums red, sore, puffy, bleeding or receded?
YesNo

Does the appearance of your smile inhibit you from laughing or smiling?
YesNo

When being photographed, do you smile with your lips closed instead of flashing a full smile?
YesNo

Are you self-conscious about your teeth or smile?
YesNo

Would you like to change anything about the appearance of your teeth or smile?
YesNo

If you answered YES to ANY of the questions above, there are often several alternatives to improve your teeth and smile. To receive a personalized response to your smile analysis, please complete the form below.

You can have the smile you’ve always wanted! To schedule a FREE, no obligation office consultation, contact us today to schedule an appointment.

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Note: Messages sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information.