Patient No. __________

Please mark a point on the line, below the question, indicating how satisfied you are with the issue covered by that question, ranging from completely unsatisfied L, to fully satisfied J. For example:

L _______________________________________________ J

How happy are you with the overall appearance of the anterior teeth?

L _______________________________________________ J

How happy are you with the shape of the anterior teeth?

L _______________________________________________ J

How happy are you with the shade of the anterior teeth?

L _______________________________________________ J

How happy are you with the size of the anterior teeth?

L _______________________________________________ J

How happy are you with the position of the front teeth?

L _______________________________________________ J

How happy are you with the appearance of the gingiva, around the front teeth?

L _______________________________________________ J

How happy are you with the appearance of any fillings, crowns or denture teeth present on the anterior teeth? (If none are present, please tick the following box ¨)

L _______________________________________________ J