ALL ABOUT YOU

Our Patients are also our friends! Please tell us about yourself so that we can get to know you better! 

    Please check next to the proper answer for each question below:

    I have difficulty cleaning my teeth: AlwaysSometimesNever
    I have difficulty eating and/ or drinking: AlwaysSometimesNever
    I have pain in my mouth or jaw: AlwaysSometimesNever
    I have difficulty talking: AlwaysSometimesNever
    I am hesitant to smile: AlwaysSometimesNever
    I cover my mouth when I talk, smile or laugh: AlwaysSometimesNever
    I am embarrassed about the way my teeth look: AlwaysSometimesNever
    People make fun of my teeth: AlwaysSometimesNever
    I worry people are looking at my teeth when I am talking: AlwaysSometimesNever
    I like to .
    I wish I could be .
    My Birthday is
    I am years old, and in the grade at school!
    I have a pet, it is a and its name is .
    My favorite thing about school is .
    My least favorite subject is .
    These friends of mine come here for their braces, too! .
    I have brothers and sisters.
    My favorite TV show is .
    My favorite food is .