Name : Age :. S.V.

:
Tel : Rrecord ID :
File ID :
Chief Complaint : .
Case Diagnosis :
1. ....
2. ...
3. .
4. ....
5. .

Treatment Plan

Extraction
Non--Extraction
Attempt for nonextraction
Surgical Referral:

Anchorage:
Upper:
Maximum Moderate Minimum

Lower:
Maximum Moderate Minimum

Using Appliance Type:

Treatment Sequences :
Upper Arch

1.
2
3
4
5
6
7
8
9
10
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.

Lower Arch

1.
2
3
4
5
6
7
8
9
10
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.

Treatment Modification
...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................................................
Retention
Upper

Lower
.

date

Operation performed in upper arch

Operation performed in lower arch

Supervisor