New Smile Questionnaire

Use this questionnaire to help determine your feelings about your smile.

1. What bothers you the most about your smile?

   _______________________________________________________________

2. Are there any spaces that you do not like? Yes/No

   Is there a need for more space? Yes/No

   Is crowding a problem? Yes/No

   Explain: _______________________________________________________________

3. (Look for esthetic problems) Ask yourself: “Does that (chip, stain, etc.) bother me?" Yes/No

   Explain: _______________________________________________________________

4. Do you like the shape of your teeth? Yes/No

   Explain: _______________________________________________________________

5. Do you like the way your bottom teeth and top teeth fit together? Yes/No

   Explain: _______________________________________________________________

6. Do you have any discolored or old fillings that bother you or that you don’t like seeing when you smile? Yes/No

7. Are your teeth as bright as you would like? Yes/No

   Explain: _______________________________________________________________

8. How would you like your smile to look?

   _______________________________________________________________

9. Has anyone ever shown you what you’d look like if you changed your smile? Yes/No

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