Smile Survey - iDental Surgery®

Smile Survey

Dental Health & Smile

What’s your biggest dental or oral health concern right now?

Bleeding gums

Bad breath

Sensitive teeth

Grinding or clenching

Crooked or misaligned teeth

Stained or discoloured teeth

Missing teeth

Jaw pain or clicking

Anxiety about visiting the dentist

I just want a general check-up

Have you ever been told you have:

Gum disease (gingivitis or periodontitis)

High plaque or tartar levels

Bite issues (overbite, underbite, crossbite)

Airway concerns or mouth breathing

None of the above / Not sure

Are you currently experiencing any of the following whole-body symptoms that may be connected to your oral health?

Low energy or fatigue

Brain fog or difficulty concentrating

Headaches or migraines

Poor sleep / snoring / mouth breathing

Digestive issues or gut discomfort

Hormonal imbalances

Skin breakouts or rashes

Joint pain or inflammation

I hadn’t thought of that connection!

What are your smile goals?

I want a whiter, brighter smile

I’d like straighter teeth

I want to replace missing teeth

I want to feel confident when I smile

I’m focused more on health than looks

I don’t really know — I just want advice

Have you had a dental hygiene clean in the last 6 months?

Yes

Are you interested in learning how your mouth might be affecting your overall health?

Yes, definitely

Maybe — I’m curious

Not right now

Do you prefer a:

Holistic, preventative approach

Just-fix-the-problem approach

I’m not sure — I just want to feel better

Is there anything else you’d like us to know to support your dental wellness journey?

Page 1 of 2

Contact Details

Your Name^*

Your Email^*

Telephone Number^*

Club iD

Yes, I would like to join Club iD and receive email updates from iDental Surgery

Page 1 of 2