Survey on patient satisfaction with dental appearance and desired treatment to improve aesthetics | |||
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1. Sex â–¡Male â–¡Female | 2. Age:___________(years) | ||
3. Education level: â–¡ Primary â–¡ Secondary â–¡ Post secondary â–¡ Tertiary | |||
1. | Are you satisfied with the general appearance of your teeth? | â–¡ Yes | â–¡ No |
2. | Are you satisfied with your tooth color? | â–¡ Yes | â–¡ No |
3. | Do you feel your teeth are crowded? | â–¡ Yes | â–¡ No |
4. | Do you feel your teeth are poorly aligned? | â–¡ Yes | â–¡ No |
5. | Do you feel your teeth are protruding? | â–¡Yes | â–¡ No |
6. | Do you have dental caries in your front teeth? | â–¡ Yes | â–¡ No |
7. | Do you have non-aesthetic fillings in your front teeth? | â–¡ Yes | â–¡ No |
8. | Do you have fractures in your front teeth? | â–¡ Yes | â–¡ No |
9. | Do you wish to undergo these treatments to improve the appearance of your teeth? | Â | Â |
 | a. Orthodontic treatment to realign teeth | □ Yes | □ No |
 | b. Tooth whitening | □ Yes | □ No |
 | c. Dental crowns | □ Yes | □ No |
 | d. Tooth coloured fillings | □ Yes | □ No |
 | e. Dentures | □ Yes | □ No |