Smile Analysis

Dental Health Questionnaire – Pacific Palisades Dentistry - Smile Analysis

Your smile affects your self-image, and can greatly influence the quality of your interactions with others. Our Pacific Palisades Dentistry team knows that many people hold back from laughing or smiling because they are uncomfortable with their smile. The following dental health questionnaire is designed to honestly appraise your smile. It touches on all things dental such as swollen gums and crooked teeth. Go to a mirror, smile wide enough to see all of your teeth, and ask yourself the following questions:

Are any of your teeth yellow, stained or somewhat discolored?

Yes No

Would you like your teeth to be whiter?

Yes No

Do you have any gaps or spaces between your teeth?

Yes No

Are any of your teeth turned, crooked, or uneven?

Yes No

Are you missing any teeth?

Yes No

Do you see any pitting or defects on the surfaces of your teeth?

Yes No

Are the edges of any teeth worn down, chipped or uneven?

Yes No

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

Yes No

Do you have any prior dental work that appears unnatural?

Yes No

Do you have any crowns or bridges that appear dark at the edge of your gums?

Yes No

Do you have any gray, black or silver (mercury) fillings in your teeth?

Yes No

Do you have a "gummy" smile (too much of your gums show when smiling)?

Yes No

Are your gums red, sore, puffy, bleeding or receded?

Yes No

Does the appearance of your smile inhibit you from laughing or smiling?

Yes No

When being photographed, do you smile with your lips closed instead of flashing a full smile?

Yes No

Are you self-conscious about your teeth or smile?

Yes No

Would you like to change anything about the appearance of your teeth or smile?

Yes No

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! To schedule a FREE, no obligation office consultation, contact us today to schedule an appointment.

Name This field is required.

Phone Please fill in phone or email address!

Email Email not in correct format.

Message

Note: Messages sent using this form are not considered private. Please contact our office by telephone if sending highly confidential or private information.

Connect With Us

Ready to come in for an appointment?
Contact us today!

Pacific Palisades Dentistry

Philip Kamins, D.D.S.

Creating Beautiful Smiles

Dr. Philip Kamins is dedicated to comprehensive dental care including Teeth Whitening, Veneers and more. We are looking forward to your visit to our Pacific Palisades, California dental office.

2024

•Site Map •Accessibility Viewer •

Site Developed by ProSites.com

Welcome
Our Practice
- Meet Our Team
- Meet Our Doctor
Patient Forms
Leave a Review
- Testimonials
Patient Information
Procedures
Contact
- Appointment Request
Pediatric Dentistry
Financing
Blog
Events