Smile Evaluation

  • Smile Evaluation

    A Simple Evaluation to Help You Obtain the Smile You've Always Wanted
  • 1. Do you like the appearance of your teeth and your smile?
  • 2. Are your teeth all in alignment (straight)?
  • 3. Do you have spaces that you don't like?
  • 4. Do you like the color of your teeth?
  • 5. Do you like the shape of your teeth?
  • 6. Are your teeth chipped?
  • 7. Are your teeth protruding?
  • 8. Are your teeth hidden?
  • 9. Are your teeth wearing on the biting surfaces?
  • 10. Are there old fillings or dental work you don't like looking at?

  • Health History

  • Birthdate*
     - -

  • Medical History

  • Are you in good health?
  • Have you been hospitalized in the past two years?
  • Do you bleed excessively when cut?
  • Do you smoke?
  • Are you taking any medication, pills or drugs?

  • Do you now have, or have you had any of the following? (If yes, describe under remarks.)

  • 1. Heart Disease
  • 2. High Blood Pressure
  • 3. Blood Disease
  • 4. Rheumatic Fever
  • 5. Heart Murmur
  • 6. Diabetes
  • 7. Stroke
  • 8. Epilepsy
  • 9. Arthritis
  • 10. Tumor History
  • 11. VD
  • 12. Nervous Disorders
  • 13. Radiation Treatment
  • 14. Liver Disease
  • 15. Kidney Disease
  • 16. Hepatitis
  • 17. Asthma
  • 18. Tuberculosis
  • 19. AIDS or HIV positive
  • 20. Allergy to:
  • 21. Are you pregnant?
  • 22. Have you ever used Fen-Phen?

  • Dental History

  • Do you have any present dental complaints?

  • I consent to whatever dental procedures and anesthetics are necessary for the treatment of the above named patient. I also agree to assume full financial responsibility for all treatment rendered.

  • Date*
     - -

  • *Once the form is submitted, a copy will be sent to your email automatically.

  • Should be Empty: