cosmetic questionnaire

1

Are any of your teeth missing?

YESNO

2

Are there spaces between any of your teeth?

YESNO

3

Are your teeth too dark or stained?

YESNO

4

Do you have crooked teeth?

YESNO

5

Do you have some teeth that are chipped?

YESNO

6

Do you have discolored fillings?

YESNO

7

Do you have crowns [caps] that show metal?

YESNO

8

Do you have crowns [caps] that have dark edges near your gum line?

YESNO

9

Is the midpoint between your two front teeth lined up with the middle of your face and nose?

YESNO

10

Do any of your teeth appear too fat, too short or too long?

YESNO

11

Do the edges of your teeth appear flat and worn?

YESNO

12

Do your eye-teeth [canines] appear too long or out of line?

YESNO

13

Do your teeth slant in one direction?

YESNO

14

Do your lips cover most of your teeth when you smile?

YESNO

15

Do you have a “gummy” smile [too much gums showing]?

YESNO

16

Are your gums red and puffy?

YESNO

17

Have your gums receded so that the root surface is visible?

YESNO

18

Look at your teeth in the upper right front of your mouth. Is the gum line at the same height when comparing the same teeth on the upper left front?

YESNO

19

Is your face symmetrical when you smile, or do your cheeks and/or lips on one side appear fuller or at different heights?

YESNO

20

Stand slightly to the side. Does the biting edges of your upper teeth follow the curvature of your upper lip?

YESNO

21

Are you happy with the appearance of your teeth and smile?

YESNO

22

Do you try to avoid being photographed?

YESNO

23

When being photographed, do you smile with your lips closed?

YESNO

24

Have you ever been embarrassed when seeing yourself smile in a home video?

YESNO

25

Do you hold back laughing out loud because of concern for how you will look?

YESNO

26

Are you inhibited from showing a full smile in front of others, especially strangers?

YESNO

27

Do you shy away from interacting with groups of people because of your smile?

YESNO

28

Do you find yourself hiding your smile by turning away or holding something in front of your mouth?

YESNO

29

When reading magazines and looking at models with beautiful smiles, have you found yourself fantasizing about having their smile?

YESNO

30

Can you think of an instance where concern for your smile has affected your work?

YESNO

31

Have you developed any habits to mask your smile?

YESNO

32

When you smile, is it spontaneous rather than forced?

YESNO

33

Are you embarrassed to visit the dentist because of what they may see in your mouth?

YESNO

34

Does your smile make you feel confident?

YESNO

35

Does your smile make you introverted?

YESNO

36

If you could “wave a magic wand,” what changes would you make in your smile?

37

Describe how a beautiful smile would make you feel.

38

If you are interested in alignment, click here and upload your photo to see how you will look after Invisalign.

39

Name

First Name

Last Name

40

Phone Number

Area Code

Phone Number

41

Email

example@example.com