Smile Questionnaire Form Patient’s name: In order to accurately evaluate your needs and expectations please help us by answering the following questions. Do you feel your teeth are: Too small or short? Yes No Too large or long? Yes No Crooked or crowded? Yes No Misshaped (uneven/pointed)? Yes No Do you feel the front teeth are too far forward (“Buck Teeth”)? Yes No Are there spaces between the teeth that you do not like? Yes No Do you see too much or too little gum tissue when smiling? Yes No Have you experienced previous orthodontic treatment (including braces, or other appliances)? Yes No If so when? Are there other issues not listed above that you would like to have changed? Yes No If yes please explain Signature Relationship to Patient Date MM slash DD slash YYYY
