|An American Academy of Cosmetic
Dentistry survey reveals that 92% of respondents say an attractive
smile is an important social asset, while 74% believe an unattractive
smile can hurt a person's chances for career success. Whether
your smile needs minor improvements or more extensive improvements,
your dentist can help.
Please print out and complete the following survey to rate your
smile. Bring this with you to your first appointment.
1 2 3 4 5 6 7 8 9 10
__ I rarely smile.
__ I smile less than I would like.
__ I smile a lot even though my smile is less than perfect.
__ My imperfect smile hurts my self confidence.
__ My imperfect smile does not bother me.
__ Other, please explain: _______________________________________________
__ Yes, I always worry about what others think about my smile.
__ Yes, I sometimes worry about what others think about my smile.
__ Yes, but I rarely worry about what others think about my smile
even though my
smile could use improvement.
__ No, I don’t worry about it.
__ I would smile more often.
__ I would feel better about myself.
__ I would have more confidence with friends, family, and on
__ My oral health would improve and be easier to maintain.
__ Other, please explain: ______________________________________________
__ I would like whiter, brighter teeth.
__ I would like to get rid of gaps between teeth.
__ I would like to repair chipped or broken teeth.
__ I would like to replace missing teeth.
__ I would like to straighten my teeth.
__ I would like to improve my oral health routine.
If yes, please explain? _________________________________________________
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