Dental Registration And History Form Page 5
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7Smile Evaluation
Name:________________________ Date:_________________
1.
Do you like the way your teeth look?
Yes □
No □
2.
Are you happy with the color of your teeth? Yes □
No □
3.
Would you like for your teeth to be whiter? Yes □
No □
4.
Would you like your teeth to be straighter?
Yes □
No □
5.
Do you have spaces between your teeth that you would like
closed?
Yes □
No □
If so, where? _____________________________________
6.
Would you like your teeth to be longer?
Yes □
No □
7.
Do you like the shape of your teeth?
Yes □
No □
Explain: _________________________________________
8.
Do you have missing teeth that you would like to replace?
Yes □
No □
9.
Do you have old silver fillings that you would like to replace
with tooth colored fillings?
Yes □
No □
Explain: _________________________________________
10. If you could change anything about your smile, what would
you change? ______________________________________
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