Smile Evaluation A Simple Evaluation to Help You Obtain the Smile You’ve Always Wanted Hold a mirror 12"–14" from your face. Smile to show your teeth. Take the time to observe your teeth carefully, and then answer the following questions: 1 Do you like the appearance of your teeth and your smile? □Yes □ No If not, explain ______________________________________________ _________________________________________________________ Are your teeth all in alignment (straight)? □ Yes □ No If not, explain ______________________________________________ _________________________________________________________ Do you have spaces that you don’t like? □ Yes □ No If yes, explain ______________________________________________ _________________________________________________________ Do you like the color of your teeth? □ Yes □ No If not, explain ______________________________________________ _________________________________________________________ Do you like the shape of your teeth? □ Yes □ No If not, explain ______________________________________________ _________________________________________________________ Are your teeth… Chipped □ Yes □ No Protruding □ Yes □ No Hidden □ Yes □ No If yes, explain ______________________________________________ _________________________________________________________ Are your teeth wearing on the biting surfaces? □ Yes □ No If yes, explain ______________________________________________ _________________________________________________________ Are there old fillings or dental work you don’t like looking at? □ Yes □ No If yes, explain ______________________________________________ _________________________________________________________ What would you like to change the most in the appearance of your teeth? _________________________________________________________ _________________________________________________________ How would you like your teeth to look? _________________________________________________________ _________________________________________________________ If you are not happy with the appearance of your teeth, ask your dentist how they can improve your smile.

Health History Mr. Mrs. Miss Ms. _____________________________________________________Birthdate_____________Age_______Soc. Sec. No._________________________ Home address__________________________________________________________City___________State__________Zip___________ Phone_____________________ Dental Insurance___________________________________________Group or Plan No.________________________Referred By________________________________ Person financially responsible___________________________________Relationship to you________________________ Soc. Sec. No._________________________ Spouse/Partner...