Form

Form

B. Sc., D.D.S.

Print and fill out this questionnaire about your smile. If you would like to explore your possibilities please call for a consultation and bring the filled in form with you.

Hold a face mirror 12"-14" from your face. Smile to show your teeth; take time to observe your teeth carefully, then answer the following questions:
1- Do you like the appearance of your teeth and your smile?								Yes	No
If not, explain:
2- Are your teeth all in alignment (straight)?								Yes	No
If not, explain:
3- Do you have spaces that you do not like?								Yes	No
If not, explain:
4- Do you like the color of your teeth?								Yes	No
If not, explain:
5- Do you like the shape of your teeth?								Yes	No
If not, explain:
6- Are your teeth:	Chipped?	Yes	No	Protruding?	Yes	No	Hidden?	Yes	No
7- How often do you get a headache?
8- Do you get a ringing and/or congestion in your ears?								Yes	No
If not, explain:
9- Are your teeth wearing on the biting surfaces?								Yes	No
If not, explain:
10- Do you have old fillings or dental work that you do not look at?								Yes	No
If not, explain:
11- What would you like to change the most in the appearance of your teeth?

12- How would you like your teeth to look?



Customized care for Head, Neck & TMJ Pain



Advanced Restorative & Aesthetic Dentistry

Web Site by CC Designs