Family, General Dentistry – Dallas TX – Dentist Mark S. Geyer – Texas 75206

8350 N. Central Expressway, Suite G-105 · Dallas, TX 75206 · P 214.363.9627 · F 214.932.1751 ·

An American Academy of Cosmetic Dentistry survey reveals that 92% of respondents say an attractive smile is an important social asset, while 74% believe an unattractive smile can hurt a person's chances for career success. Whether your smile needs minor improvements or more extensive improvements, your dentist can help.

Please print out and complete the following survey to rate your smile. Bring this with you to your first appointment.

  1. Rate your smile on a scale of 1-10, with 10 being perfect:
    HELP! ------------ PERFECT!

  2. If you feel your smile is less than perfect, how does this affect you?

    • __ I rarely smile.
    • __ I smile less than I would like.
    • __ I smile a lot even though my smile is less than perfect.
    • __ My imperfect smile hurts my self confidence.
    • __ My imperfect smile does not bother me.
    • __ Other, please explain: __________________________________________________
  3. Are you ever worried what other people think about your smile?

    • __ Yes, I always worry about what others think about my smile.
    • __ Yes, I sometimes worry about what others think about my smile.
    • __ Yes, but I rarely worry about what others think about my smile even though my smile could use improvement.
    • __ No, I don't worry about it.
  4. How do you think that having a perfect smile would improve your life? (check all that apply)

    • __ I would smile more often.
    • __ I would feel better about myself.
    • __ I would have more confidence with friends, family, and on the job.
    • __ My oral health would improve and be easier to maintain.
    • __ Other, please explain: __________________________________________________
  5. What would you like to improve about your smile? (check all that apply)

    • __ I would like whiter, brighter teeth.
    • __ I would like to get rid of gaps between teeth.
    • __ I would like to repair chipped or broken teeth.
    • __ I would like to replace missing teeth.
    • __ I would like to straighten my teeth.
    • __ I would like to improve my oral health routine.
  6. Do you ever have any tooth pain or discomfort?

    If yes, please explain? __________________________________________________

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