How do you feel about Dental Visits?	Relaxed Anxious Nervous
How often do you brush your teeth?
How often do you floss your teeth?
Do you grind or clench your teeth?	Yes No
When you look in the mirror, do you like the appearance of your teeth?	Yes No
Do you have any stained teeth?	Yes No
Do you like the color of your teeth?	Yes No
Do you have any spaces between your teeth?	Yes No
Do you have any chips or cracks in your teeth?	Yes No
Do you like the length of your teeth?	Yes No
Do your teeth look prematurely aged?	Yes No
Do you have any crooked teeth?	Yes No
Do you like the shape of your teeth?	Yes No
Do you have any areas where your gums have receded?	Yes No
Are you missing any teeth?	Yes No
Do you have unattractive silver fillings?	Yes No
Do you have teeth that you believe need crowns?	Yes No
Do you have any unattractive crowns that have metal showing through?	Yes No
Does too much gum tissue show when you smile?	Yes No
Would you like to see what you would look like with a great looking smile?	Yes No
Would you like our office to call you for a complimentary smile evaluation and consultation?	Yes No
If so please fill out the information below or call us!
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