Your Smile Assessment
Tick what applies. Add up your points. Your total shows us where to begin.
Name
First Name
Last Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
1 YOUR SMILE TODAY Tick all that apply · 1 point each
Section score / 5
1 YOUR SMILE TODAY
Missing teeth
Crooked teeth
Discoloured teeth
Broken teeth
Gappy teeth
2 WHAT YOU EXPERIENCE Tick all that apply · 1 point each
Section score / 9
2 WHAT YOU EXPERIENCE
Bleeding gums
Difficulty chewing
Pain
Food collecting around teeth
Inability to chew
Embarrassment of smiling
Avoids eating in social situations
Avoids certain foodstuffs when eating
I am nervous and need sedation
3 YOUR END GOAL Choose one in each box
Section score / 11
If all of the above was carried out, how would that make you feel?
1 (+1 pt) A little better
2 (+2 pts)
3 (+3 pts)
4 (+4 pts)
5 (+5 pts) Life-changing
How soon are you looking to get this treated?
Within the next 3 months +4 pts
3 to 6 months +3 pts
6 to 12 months +2 pts
12 months plus +1 pt
Budget and payment options
I am unaware of the costs and need to discuss that. +0 pts
I am not concerned about the costs. +1 pt
I am looking at finance and payment options. I know my costs, as I have a treatment plan already. +2 pts
Your Smile Score Section 1 + Section 2 + Section 3 Total / 25
0–5
Routine
Refine and enhance at your pace.
6–10
Planned
Time to explore your options.
11–15
Priority
Treatment will make a real difference.
16–20
Urgent
Comfort and function are affected. Act soon.
21–25
Immediate
Book your consultation now.
For clinic use: band
initials
Natural Smiles · Leicester 0116 218 2181 · Corby 01536 206900
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