Oral Function & Smile Evaluation Questionnaire

Please take a few minutes to give us the following details to help us to understand your needs and in return we can best help you to achieve a healthy mouth for a lifetime.

What is the primary reason for your visit?
When was the last time you visited the dentist? What brings you to us?
When was your last hygiene treatment?
How did you hear about us?
Do you have a clicking jaw?
Do you grind your teeth?
Do you have pain when opening wide?
Do you suffer from headaches or neck pain?
Have you noticed any teeth wearing down?
Do you have any missing teeth you would like to replace?
If yes, would you be interested in implants?
Do you like the way your teeth look?
If no please explain briefly:
Are you happy with the colour of your teeth?
Would you like your teeth to be whiter?
If yes, are you considering teeth whitening?
Are your teeth crowded, would you like them to straighter?
Are your teeth crowded, would you like them to straighter?
If so, where?
If you could change anything about your smile, what would it be, and why?
If we take any photographs, can we use them for in-house and external marketing?
Please SIGN by retyping your full name below: