Please print out and complete the following survey to rate your smile. Bring this with you to your first appointment.

1) Rate your smile on a scale of 1-10, with 10 being perfect:
 
1   2   3   4   5   6   7   8   9   10
HELP!--------------------PERFECT!

2) If you feel your smile is less than perfect, how does this affect you?

__ I rarely smile.
__ I smile less than I would like.
__ I smile a lot even though my smile is less than perfect.
__ My imperfect smile hurts my self confidence.
__ My imperfect smile does not bother me.
__ Other, please explain: __________________________

3) Are you ever worried what other people think about your smile?

__ Yes, I always worry about what others think about my smile.
__ Yes, I sometimes worry about what others think about my smile.
__ Yes, but I rarely worry about what others think about my smile even though my smile could use improvement.
__ No, I don’t worry about it.

4) How do you feel that having a perfect smile would improve your life? (check all that apply)

__ I would smile more often.
__ I would feel better about myself.
__ I would have more confidence with friends, family, and on the job.
__ My oral health would improve and be easier to maintain.
__ Other, please explain: _________________________________________

5) What would you like to improve about your smile? (check all that apply)

__ I would like whiter, brighter teeth.
__ I would like to get rid of gaps between teeth.
__ I would like to repair chipped or broken teeth.
__ I would like to replace missing teeth.
__ I would like to straighten my teeth.
__ I would like to improve my oral health routine.

6) Do you ever have any tooth pain or discomfort?

If yes, please explain? _________________________________________________

 
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