Smile Self-Analysis Form

Smile Awareness

1.	Do you consider a smile to be an important facial feature? Yes No
2.	Do you notice other peoples' smiles? Yes No
3.	When you read a fashion magazine, are your eyes drawn to the model's smile? Yes No
4.	Is there someone's smile you admire? Yes No Who?   Why?
5.	Are you self-conscious about smiling in front of others? Yes No
6.	Do you put your hand up to cover your mouth when you smile or talk? Yes No

Smile Analysis

1.	Do you have fillings that are visible? Yes No
2.	Do you want any fillings replaced? Yes No
3.	Are some teeth darker than others? Yes No
4.	Do your teeth have white or brown stains? Yes No
5.	Do you wish you could have a whiter, more youthful smile? Yes No
6.	Do you see any minor defects in the appearance of your teeth or your gums? Yes No
7.	Are there spaces or gaps between any of your teeth? Yes No
8.	Have you noticed any increase in the spaces or gaps? Yes No
9.	Do you pack food between any teeth when you eat? Yes No
10.	Are some teeth too long and/or too short? Yes No
11.	Are some teeth crooked, chipped or jagged? Yes No
12.	Do you show your gums when you smile? Yes No
13.	Do your bottom teeth follow the outline of your lower lip? Yes No
14.	When you smile, do your top teeth follow the outline of your lower lip? Yes No
15.	How would you rate your existing smile on a scale of 1-10, with a 10 being a picture-perfect Hollywood smile? 1 2 3 4 5 6 7 8 9 10
16.	Where would you like your smile to be on a scale of 1-10, with a 10 being a picture-perfect Hollywood smile? 1 2 3 4 5 6 7 8 9 10
17.	What, if anything, about your teeth or smile would you like to change?
18.	Would you like to have a glamorous, picture-perfect Hollywood smile or would you like to have an enhanced, natural, pleasing smile? Perfect Natural
19.	Which of the following dental procedures are you familiar with? Cosmetic Contouring Ceramic Onlays Whitening Bonding Porcelain Veneers Crowns (Caps) Implants Bridges
20.	Which of the following dental procedures do you believe would benefit you? Cosmetic Contouring Ceramic Onlays Whitening Bonding Porcelain Veneers Crowns (Caps) Implants Bridges
21.	What are your concerns regarding cosmetic dental procedures? Looking Natural Comfort Time Beauty Quality Value Insurance Durability Age   Fees  Safety Other "If you checked Other, would you please explain briefly:

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