Orthodontic Questionnaire


Please tell us why you have presented for evaluation and possible treatment :

Crowding

Dont like my smile

Appearance

Better function

Teasing at school

If the patient has ever sucked their thumb
YesNo

Patient plays a musical (mouth) instrument finger, until what age?
YesNo

Patient has consulted an orthodontist or another dentist?
YesNo

Does the patient have any speech problems?
YesNo

Does the patient breathe through the mouth?
YesNo

Has one or more parent had previous ortho treatment?
YesNo

Do you feel your front teeth “stick out too much” (buck teeth)?
YesNo

Are there spaces between your teeth that you do not like?
YesNo

Is there too much or too little gum tissue showing when you smile?
YesNo

Has there been previous orthodontic treatment (including braces or other appliances)?
YesNo

If so, when and by whom?
YesNo

Are there other dental issues not listed above that you would like to discuss or have treated?
YesNo


If you answered YES to ANY of the questions above, there are often several alternatives to improve your teeth and smile. To receive a personalized response to your smile analysis, please complete the form below.

You can have the smile you’ve always wanted! contact us today to schedule an appointment.