Smile Assessment Form

It is our goal to offer dental solutions that align with what is most important to you. Your smile is an important aspect of your appearance and how you present yourself. The questions below will help us identify and address you areas of concern.

Please answer the following questions:

Do you like the way your teeth look?

Do you ever have difficulty eating, chewing or drinking?

Do you have teeth that are crooked, misaligned, crowded, or uneven?

Do you have difficulty flossing you teeth due to crowding?

Do you have gaps / spaces between your teeth that you would like closed?

Would you like your teeth to be straighter?

Are the edges of your teeth chipped, or worn down?

Are your gums red, sore, puffy, bleeding or receding?

Have you had previous orthodontic treatment?

Have you noticed your teeth shifting or moving?

Are you self-conscious about your teeth or avoid showing your teeth when smiling?

Do you snore?

Have you ever been diagnosed with Sleep Apnea?

Rate your smile on a scale of 1-10 (10 being very happy)

If you could change anything about your smile what would it be?

What has stopped you from getting these issues addressed in the past?

If we could help fix any or all of these concerns you listed would you like to learn more?

Have you ever considered invisible clear aligner or other forms of orthodontic therapy?

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Smile Assessment Form

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