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Dentistry At Its Finest
Print blank form to fill by hand


  Last name

  Mid Initial

  First name

Smile Makeover Questionnaire

1. Are you embarrassed and self-conscious by your smile? Yes No
2. Is this a new problem that occurred the last few years or a lifelong problem?
Recent Lifelong
3. Do you cover your mouth with your hand when you go to laugh? Yes No
4. Is it one tooth, many of your teeth, or all your teeth that bother you?
One Multiple All
5. Is it your upper front teeth, lower front teeth or both that bother you?
Upper Lower Both
6. Do you think your smile negatively affects the way people view you? Yes No
7. Do you think your smile is negatively affecting your job or relationship possibilities? Yes No
8. How much bigger problem are your teeth, in your life?
Huge Moderate Slight
9. Do you have prior dental work that looks unnatural or has dark lines along the gum line? Yes No
10. What problems about you smile would you like to correct?
Eliminate Spaces between teeth
Eliminate spaces at gum line
Teeth overlapped/crowded
Gum line uneven
Teeth worn down
Edges of teeth chipped
Yellow or discolored teeth
Size of teeth not pleasing: Too wide Too narrow Too long Too short
11. Do you have missing teeth that affects your smile? Yes No
12. How would you rate your smile?
Horrible Not Spectacular Just Ok Pretty Good Close To Perfect
13. Do you think your smile can be fixed or do you think your teeth are hopeless?
Treatable Problems Hopeless Problems
14. Is there anything else you would like Dr. Matarazzo to know about you or your smile?
*Signature:
Date:
(Your digital signature (full name) is as legally binding as a physical signature.)