SMILE ASSESSMENT

    Please consider each statement carefully and circle YES or NO. The doctor and members of the dental team will discuss your responses with you in confidence.

    1. I am concerned about the appearance of my teeth or my smile.

    2. I am concerned about the whiteness/ lack of whiteness of one or more of my teeth.

    3. I am concerned about the position or angle of one or more of my teeth.

    4. I am concerned about the shape of one or more of my teeth.

    5. In social situations, I am sometimes embarrassed by my teeth or my smile.

    6. There are some things about my upper front teeth that I would like to change.

    7. There are some things about my lower front teeth that I would like to change.

    8. I have old fillings or previous dental treatment that is no longer satisfactory to me.

    9. I am missing one or more of my teeth.

    10. I am interested in learning more about esthetic dentistry.