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Patient Expectations Questionnaire

    Are you currently:

    Yes / No

    Too Small Or Short?

    YesNo

    Too Large Or Large?

    YesNo

    Crooked/Crowded Or Overlapped?

    YesNo

    Do You Feel You Front Teeth "Stick-Out" Too Much?

    YesNo

    Misshaped?

    YesNo

    Are There Spaces Between Your Teeth That You Do Not Like?

    YesNo

    Face: are you happy with your:

    Yes / No

    Lips

    YesNo

    Nose

    YesNo

    Jaws / Jaw Line

    YesNo

    Other

    YesNo

    Symptoms: if you want to reduce pain or discomfort, where is it located?

    Yes / No

    In Front Of My Ears

    YesNo

    INear My Ears

    YesNo

    Neck / Shoulders

    YesNo

    Temples

    YesNo

    Eyes

    YesNo

    Teeth

    YesNo

    Sinuses

    YesNo

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