Professional Teeth Whitening Questionnaire
1. When did you have your last teeth cleaning?
1-30 Days
1-6 Months
7-12 Months
1-2 Years
More than 2 years
2. Do any of your front teeth have bonding, a crown or a veneer?
Yes
No
Not sure
Other
3. When would be the best time for you to whiten your teeth (i.e., at-home)?
Overnight
Morning
Mid-day
Evening
Other
4. Do you grind your teeth?
Yes
No
Not sure
Other
5. Have you previously used a teeth whitening product?
Yes
No (Proceed to #6)
5a. If yes, what kind?
Professional in-office
Professional at-home
Over-the-counter strips
Other
5b. How long ago did you whiten your teeth?
6 months or less
7-24 months
More than 2 years
5c. Did you experience any sensitivity of the teeth or gums?
Yes
No
Do not remember
Not sure
Other
5d. Were you satisfied with the results?
Yes
No
Sort of
Other
5e. If you were not fully satisfied, please explain:
6. Are any of your teeth presently sensitive to (check all that apply):
Hot
Cold
Sweets
Not sure
Other
7. How often do you smoke?
Everyday
Occasionally
Never
Other
8. Do you have an upcoming event (e.g., wedding, vacation or reunion) for which you would like a whiter smile?
Yes
No
Possibly
Other
9. Has anyone ever suggested that you should whiten your teeth?
Yes
No
Not sure
Other
10. When you smile, do you have one or two teeth that stand out because they are darker?
Yes
No
Possibly
Other
11. Are you interested in having your teeth whitening last “as long as possible?”
Yes
No
Maybe
Other
12. Women: Are you pregnant or nursing a newborn?
Yes
Pregnant
Nursing
No
Not Applicable
13. I am interested in (check all that apply) :
*
Entry Level Whitening
Instant In-Office Whitening
Custom At-Home Whitening
Manhattan Method for Whitening and Uneven Smile
Power Whitening
Not sure
Name
*
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
Print Form
Please Submit to Dr. Davis
Clear Form
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