If you have any concerns about your smile, please answer the following questions:

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

Yes No

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

Yes No

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

Yes No

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

Yes No

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

Yes No

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

Yes No

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

Yes No

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

Yes No

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

Yes No

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

Yes No

11. Would you like your teeth to be straighter?

Yes No

12. Do you feel you show too much gum tissue?

Yes No

13. On a scale of 1-10 (10 being the best) how would you rate your smile?

1 2 3 4 5 6 7 8 9 10