AN ISO 9000:2008 CERTIFIED CLINIC
020-26650648
TAKE A SMILE TEST
Name:
Email
Phone:
BirthDate:
Are you happy with the appearance of your teeth?
Yes
No
Are your teeth crooked, overlapping or gapped?
Yes
No
Are any of your teeth chipped, uneven, or broken?
Yes
No
Do you clench or grind your teeth?
Yes
No
Do you have pain or sensitivity with your teeth?
Yes
No
Do you notice any red or white patches in your mouth?
Yes
No
Do you dislike the color of your teeth?
Yes
No
Would you like to improve your existing smile?
Yes
No
If YES, what would you like to change about your teeth? Please explain:
Do you have receding gums or gums that bleed?
Yes
No
Are any of your teeth loose?
Yes
No
Do you notice bad breath or dry mouth (Xerostomia)?
Yes
No
Is there a family history of Periodontal Disease?
Yes
No
Have you ever taken/used or currently take/use any of the following?
Tobacoo
Alcohol
Recreational Drugs
None
Please check off any concerns that would potentially stand in the way of dental treatment to improve your smile:
Anxiety
Not understanding Treatment
Time or length of treatment
Embarrassment
financial Concerns
Trust
Distance to office
Other
Thank you for taking the time to complete your Smile Assessment
