Power-Smile.com - Assess Yourself

Please take a moment to review our self-assessment survey. If you answer yes to any of these screening questions, you may have a dental condition in need of attention.

If you would like to discuss your concerns with Dr. Gay, please indicate your answers and submit the form and our office will call you to schedule an appointment. You may also schedule an appointment by calling 513.381.7900.

About Your Smile

About Your Gums and Breath

Are you self conscious about smiling?
Yes No
When you look at your smile in the mirror, do you see any defects in your teeth or gums?
Yes No
Do you wish your teeth were whiter?
Yes No
If you have any fillings in your front teeth, do they match the color of the tooth?
Yes No
If you have any crowns, veneers, laminates or bonding, do you think they look natural?
Yes No

Are your gums red, swollen, tender; or do they bleed easily?
Yes No
Do you have a persistent bad taste in your mouth or bad breath?
Yes No
Are your teeth becoming loose or starting to separate?
Yes No
Does your tongue feel coated?
Yes No

About Your Jaw Muscles

About Snoring and Sleeping

Do you hear noises from your jaw joint?
Yes No
Does your jaw get "stuck", "locked", or "go out" when you talk, yawn, or eat?
Yes No
Does your bite feel uncomfortable, unusual, or painful when chewing?
Yes No
Do you have pain in or about the ears or cheeks?
Yes No
Does your bite feel uncomfortable, unusual, or painful when chewing?
Yes No

Have you been told your breathing stops while asleep?
Yes No
Are you aware or have you been told you snore?
Yes No
Do you wake feeling you have not slept?
Yes No
Do you feel sleepy during the day?
Yes No
Do you often wake with a headache?
Yes No

To send us your answers and to request an appointment, please provide the following information:

Your name
E-mail address (name@company.com)
Daytime telephone
Are you a currently one of Dr. Gay's patients? Yes No
Would you like to receive future news and information updates about Dr. Gay's practice via e-mail? Yes No
To request an appointment without filling out this form, call 513.381.7900.
Privacy notice: By submitting this form you will transmit your responses to the self-assessment and contact information to the office of Dr. Walter E. Gay, Jr., DDS. We will not disclose this information to any 3rd party without your permission and the information is used to help us contact you to schedule an initial office visit and consultation. To have your name removed from our e-mail list, please e-mail us at info@power-smile.com.