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(337) 704-2126 Schedule an Appointment 1601 Kaliste Saloom Rd, Lafayette LA 70508

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home
about us
patient services
patient information
- Loyalty Dental Plan
blog
contact us
Search

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SMILE & HEALTH EVALUATION FORM

we want you to love your smile!

Please fill out the form below. If you have trouble filling out this form online, please email beth@maestridental.com to send you a printable version of the form to fill out and bring with you to your next appointment.

* Required


                        First Name* 
Last Name* 
Email*
                            
                        
Do you like the overall appearance of your teeth, your smile?*
								
								Yes!
							

								
								No - chipping
							

								
								No - protruding
							

								
								No - artificial looking
							

								
								No - crowded/spacing
							

								
								No - excessively worn (short teeth)
							

								
								No - shape
							

								
								No - other
							
Do you like the color of your teeth?*
								
								Yes!
							

								
								No - coffee/tea stains
							

								
								No - tobacco stains
							

								
								No - discolored fillings
							

								
								No - tetracycline stains
							

								
								No - silver filling stains
							

								
								No - other
							
Do you consider your existing fillings or dental work to be attractive*
								
								Yes
							

								
								No
							

								
								N/A
							
Do you think your gums are attractive?*
								
								Yes!
							

								
								No - swollen
							

								
								No - reddened
							

								
								No - bleed easily
							

								
								No - Halitosis (bad breath)
							

								
								No - excessively receded
							

								
								No - crowns are ill-fitting
							

								
								No - difficult to clean between teeth
							

								
								No - other
							
When was your last dental visit?* 
How often do you see the dentist?* 
Have you had any dental issues that cause you discomfort? If yes, explain. If no, please leave N/A* 
Have you ever experienced any of the following problems with your jaw?*
								
								No
							

								
								Clicking
							

								
								Pain (joint, ear, face)
							

								
								Difficulty opening/closing
							
Do you have frequent headaches?*
								
								Yes
							

								
								No
							

								
								N/A
							
Do you clench or grind your teeth?*
								
								Yes
							

								
								No
							

								
								N/A
							
Have you ever had Botox for cosmetic purposes or for TMJ pain?*
								
								Yes
							

								
								No
							
Do you snore or have you ever been told you snore?*
								
								Yes
							

								
								No
							
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welcome

Welcome to exceptional family dentistry in Lafayette. Dr. Gina Liggio Maestri DDS and her team of dedicated dental professionals are here to provide you and your family with a level of caring clinical excellence you’ve never experienced before. From our state-of-the-art technology to our many comfort amenities, we have everything you need to feel relaxed while you enjoy gentle dentistry in Acadiana.

find us @

1601 Kaliste Saloom Rd
Lafayette, LA 70508

337-704-2126

SCHEDULE AN APPOINTMENT

Maestri icon

find us @

1601 Kaliste Saloom Road
Lafayette, LA 70508

337-704-2126

SCHEDULE AN APPOINTMENT

© Gina Liggio Maestri, DDS Family Dentistry 2019

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