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Woodland, CA Family Orthodontist
Call Us: (530) 662-9191
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Why Choose Portalupi
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Home
Why Choose Us?
Why Choose Portalupi
Meet Dr. Portalupi
Meet Your Team
Invisalign
How Does Invisalign Work?
Invisalign® for Adults
Invisalign® for Teens
Braces
Different Types of Braces
Braces for Adults
Braces for Teens
New Patients
What to Expect
Financing & Insurance
Patient Forms
Blog
Appointments
In-Office Consultation
Virtual Consultation
Contact Us
Patient Smile Evaluation
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Patient Smile Evaluation
Patient Forms
Patient Smile Evaluation
Please hold a full face mirror 12” to 14” from your face. Smile to show your teeth. Take time to observe your teeth carefully. Then answer the following questions.
Patient's Name (First, Middle, Last)
*
Date of Birth (mm/dd/yyyy)
*
Do you like the overall appearance of your teeth / smile?
*
Yes
No
If NO, please explain
Do you think your teeth are in good alignment (straight)?
*
Yes
No
If NO, please explain
Do you have spaces between your teeth that you don’t like?
*
Yes
No
If YES, please explain
Do you like the color of your teeth?
*
Yes
No
If NO, please explain
Do you like the shape of your teeth?
*
Yes
No
If NO, please explain
Do you think your teeth are attractive?
*
Yes
No
If NO, are your teeth:
Chipped
Overlapping
Protruding
Excessively Worn
Hidden
Artificial Looking
Do you like the way your upper and lower teeth come together?
*
Yes
No
If NO, please explain
Do you consider your existing fillings or dental work to be unattractive?
*
Yes
No
If YES, please explain
Do you think your gums are unattractive?
*
Yes
No
If YES, are your gums:
Swollen
Excessively Receded
Red
Crowns Ill-fitting
Bleed easily
Hard to clean between teeth
What, if anything, would you like to change the most about your teeth or smile?
Home
Why Choose Us?
Why Choose Portalupi
Meet Dr. Portalupi
Meet Your Team
Invisalign
How Does Invisalign Work?
Invisalign® for Adults
Invisalign® for Teens
Braces
Different Types of Braces
Braces for Adults
Braces for Teens
New Patients
What to Expect
Financing & Insurance
Patient Forms
Blog
Appointments
In-Office Consultation
Virtual Consultation
Contact Us
Home
Why Choose Us?
Why Choose Portalupi
Meet Dr. Portalupi
Meet Your Team
Invisalign
How Does Invisalign Work?
Invisalign® for Adults
Invisalign® for Teens
Braces
Different Types of Braces
Braces for Adults
Braces for Teens
New Patients
What to Expect
Financing & Insurance
Patient Forms
Blog
Appointments
In-Office Consultation
Virtual Consultation
Contact Us
