Smile Analysis Questionnaire
Yes
No
Do 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 Twain
Are there old crowns, bridges or fillings that you don’t
Can 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?
No
Yes
Yes
No
Yes
No
No
Yes
First Name:
Yes
No
No
Yes
No
Birthdate:
Last Name: