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.