1. Are you pleased with the general appearance of your teeth and smile?
Yes No   If not, explain 

2. Are your teeth straight?
Yes No   If not, explain 

3. Are there spaces between your front teeth that you dislike?
Yes No   If yes, describe? 

4. Are you satisfied with the color of your teeth?
Yes No   If not, explain 

5. Are you satisfied with the shape of your teeth?
Yes No   If not, explain 

6. Are any of your teeth
Chipped?
Protruding?
Hidden?
If so, describe

7. Are you satisfied with the way your teeth come together?
Yes No   If not, explain 

8. Do you have old fillings or dental work that makes you less confident about your smile and/or appearance?
Yes No   If yes, explain 

9. What would you most like to change about the appearance of your teeth?

10. How would you like your teeth to look to maximize your smile?

Additional comments.

Now that you have completed this questionnaire, we would like to review your responses with you. There are probably several alternatives we can suggest to help you achieve a more pleasing smile. We'll write or call you back with some possible solutions for your particular condition.

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