1.

How many teeth do you show with your
best smile?

2.

My teeth seem too dark.

Yes No

3.

How would you describe their color and shade?

	very white		moderate - white		light - yellow
	moderate - yellow		dark - yellow		light - brown
	dark - brown		moderate - grey		dark grey

4.

How are color and shade distributed?
Even Uneven

5.

Do you have white or discolored spots on your teeth?

Yes No

6.

Do you see any pitting or defects on the surface
of your teeth?

Yes No

7.

Do your front teeth have any visible fillings
and/or crowns?

Yes No

8.

Are your teeth crowded?

Yes No

9.

Do you have spaces between your teeth?
How many?

Yes No

10.

What shape and size do your teeth have? Please choose one value per section.

Section 1	Section 2	Section 3	Section 4	Section 5
Long	Narrow	Large	Square	Irregular
Short	Wide	Small	Round	Regular
Normal	Normal	Normal	Tapered

11.

I see significant differences between
neighboring teeth.

Yes No

12.

I show my gums when I smile.

Yes No

13.

I like the amount of gums that I show.

Yes No

14.

How would you describe your lips?

Very Full

Full

Normal

Narrow

15.

Is there anything you would like to mention about your smile? How did you find us? Use the text area for your comments.

16.

I want to stay current on all latest advances in smile improvement technology, so please send me more information

Yes No