Virtual Smile Consultation Virtual Smile Consultation Name* First Last Patient Age* Phone*Email Address* Message concern PLEASE ANSWER YES OR NO TO THE FOLLOWING:BITE AND JAW JOINTQuestion 1*1. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)* Yes No Question 2*2. Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together?* Yes No Question 3*3. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?* Yes No Question 4*4. In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed?* Yes No Question 5*5. Are your teeth becoming more crooked, crowded, or overlapped?* Yes No Question 6*6. Are your teeth developing spaces or becoming more loose?* Yes No Question 7*7. Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together?* Yes No Question 8*8. Do you place your tongue between your teeth or close your teeth against your tongue?* Yes No Question 9*9. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?* Yes No Question 10*10. Do you clench or grind your teeth together in the daytime or make them sore?* Yes No Question 11*11. Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth?* Yes No Question 12*12. Do you wear or have you ever worn a bite appliance?* Yes No SMILE CHARACTERISTICSQuestion 13*13. Is there anything about the appearance of your teeth that you would like to change (shape, color, size)? * Yes No Question 14*14. Have you ever whitened (bleached) your teeth?* Yes No Question 15*15. Have you felt uncomfortable or self conscious about the appearance of your teeth?* Yes No Question 16*16. Have you been disappointed with the appearance of previous dental work?* Yes No Captcha protectedNameThis field is for validation purposes and should be left unchanged. Δ BOOK AN Appointment BOOK AN APPOINTMENT
