Do you regularly enjoy tobacco, coffee, tea, red wine, and/or soft drinks?

Yes No

Do you eat a lot of dark fruit (eg. blueberries and purple grapes), light fruit (eg. melons and peaches), chocolate, and/or cheese?

Yes No

Are the stains on your teeth yellowish, brownish, and/or grayish/purplish?

Yes No

Have you considered any of the following: whitening toothpastes, over-the-counter gels or strips, professional bleaching, veneers?

Yes No

Do you have fillings, crowns, bridges, bonding, or dentures?

Yes No

Are you pregnant or breastfeeding, have sensitive or receding gums, or allergic to peroxide?

Yes No

Do you currently use an electric toothbrush and/or whitening toothpaste?

Yes No