YesNoDo you cover your mouth when you talk or smile?Do you feel uncomfortable or self-conscious about your smile?Yes“The Shortest distance between two people is a smile.”Smile Analysis Questionnaire– Mark TwainAre there old crowns, bridges or fillings that you don’tCan you see dark restorations in your teeth that bother you?What would you like your smile to look like?like the appearance of?Do you wish your teeth were whiter?Are your teeth in alignment (straight)?Are your teeth chipped?Do you like the shape of your teeth?NoYesYesNoYesNoNoYesFirst Name:YesNoNoYesNoBirthdate:Last Name: