Pearly Teeth Wax Pre-Study Questionnaire
Purpose: Demonstrate observed effects of our proprietary formula on tooth strength, enamel appearance, and oral comfort.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date
-
Month
-
Day
Year
Date
What is your biggest motivation to help your teeth holistically?
Tooth pain
Infection
Tooth decay
Overall mouth health
Other
Which age group do you belong to?
15–29
30–44
45–59
60–74
75–89
Overall, how sensitive are your teeth to common triggers such as hot, cold, sweet, sour, pressure, or brushing? (1 = Not sensitive at all 10 = Extremely sensitive)
Please rate the overall strength of your teeth in areas you believe may have cavities or decay (1 = Very weak, 10 = Very strong).
Please rate your perception of your teeth in the areas where you will be using Pearly (1 = Enamel appears rough or decaying, 10 = Enamel appears smooth and improving)
On a scale of 1-10, How motivated are you to help your mouth? (1 = Not motivated at all 10 = Extremely motivated)
Would you be open to adjusting your diet to better support your dental health? (1 = Not open to modifying my diet 10 =Very willing to modify my diet)
How willing are you to manage your stress through exercise, meditation, or lifestyle changes? (1 = Not willing at all, 10 = Extremely willing)
How willing are you to address the emotional side of tooth decay by exploring strong feelings through: self reflection, journaling, letting go... (1 = Not willing at all, 10 = Extremely willing)
Are you consistent in supporting your body’s healing?
Please Select
very consistent
somewhat consistent
inconsistent
How willing are you to spend 5 minutes or less per day applying the Pearly? (1 = Not willing at all, 10 = Extremely willing)
To support the most accurate assessment, please upload a pre-treatment image of any area(s) of concern before beginning. Participation is optional, and all images are anonymous. Submissions help us evaluate product effectiveness.
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Your input is highly valuable for the future of holistic dental care.
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