Patient Smile Evaluation

Patient Name*

First NameLast Name
Date*

MonthDayYear
Date
We would like to thank you for choosing Natural Dentistry for your dental needs and would like to ask you to take a few minutes and answer some questions. This is to ensure us we are getting any and all dental concerns you may have addressed at your visit today.

Please circle one.
Do you dislike the color of your teeth?*

YesNo
Do you have spaces between your teeth?*

YesNo
Do you have chips or uneven edges on your teeth?*

YesNo
Do you feel your teeth are too long or too short?*

YesNo
Do you have dark “mercury” fillings that show when you smile?*

YesNo
Do your gums show too much when you smile?*

YesNo
Do you feel your teeth are crowded or crooked?*

YesNo
Do you have any dental work that you consider is ugly?*

YesNo
Are you self-conscious about your teeth or smiling?*

YesNo
Would you like to improve something about your teeth or smile?*

YesNo
Do you snore?*

YesNo
Does your spouse say you grind your teeth at night?*

YesNo
Is your breath as fresh as you would like?*

YesNo
Should be Empty: