Dr Maddahi's Spa Dentistry

Evaluate Your Smile for Our Office

1. Does your smile worry or introvert you?
   Choose One... Always Often Sometimes Rarely Never
   
   
   
2. Is there anything you consider to be ugly about your smile?
   Choose One... I hate my smile I don't like my smile I haven't thought about it I like my smile but would like to make it better I love my smile
   
   
   
3. Do you avoid smiling when greeting others or being photographed?
   Choose One... Always Often Sometimes Rarely Never
   
   
   
4. Has anyone teased you about your smile or suggested you should make a change?
   Choose One... Yes No
   
   
   
5. Have you ever wished you could have whiter teeth?
   Choose One... Yes No
   
   
   
6. Do you have any spaces between your teeth that you wish were not that way?
   Choose One... Yes No
   
   
   
7. Do you have chips or rough edges that are unsightly and bother you?
   Choose One... Yes No
   
   
   
8. Does your smile reveal unsightly fillings, caps, crowded, or crooked teeth?
   Choose One... Yes - Unsightly fillings Yes - Caps Yes - Crowded teeth Yes - Crooked teeth Yes - Two or more of these problems No - My smile has none of these problems
   
   
   
9. Are your gums painfully obvious when you smile?
   Choose One... Yes No
   
   
   
10. Would you like to improve your smile in any way?
    Choose One... Yes, I would! I don't think my smile can improve.
    
    
    

Please take a moment to choose from among the following statements about what worries or fears you may have in relation to your teeth and the treatment you've had prior to coming to Dr Maddahi.

11. Which of the following worry you?
    (check all that apply)
    
     I am afraid of painful treatment
     I am afraid of dentists
     I have let the situation with my teeth go too long
     I have had a horrible experience with dental treatment
     I am afraid I can't afford to fix everything I need to
     I am embarrassed about my teeth/oral health
     I am worried about finding or getting to your offices
    

Thank you for your candid answers. I will be very happy to address these with you in person further if you want. Please feel free to contact me at any time. Thanks!
Dr. Kourosh Maddahi

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