Date: ________________

Patient Information
Name: ______________________________ Sex: Male Female
Age: ________ Birth Date: ______________ Marital Status: ________________
Home Phone: ________________________ Cell Phone: ___________________
Home Address: ____________________________________________________
Hobbies/ Activities:__________________________________________________
Occupation: _______________________________________________________
Have we treated another member of your family? YES NO
If YES, Name: ___________________________
What are the main concerns that you would like orthodontics to accomplish?
____________________________________________________________
Have visited an orthodontist before? YES NO
If YES, for what reason? ________________________________________

Medical and Dental History

Are you currently under the care of a physician? YES NO
If YES, for what reason? ________________________________________
History of major illness? YES NO If YES, describe___________________
Any allergies? YES NO If YES, list _____________________
Currently taking medications? YES NO If YES, List____________________
Do you smoke Tobacco? YES NO If yes, frequency_________________
Have you been treated any of the following?
Arthritis Blood Disorders Diabetes Heart Condition
Asthma Cancer Epilepsy High blood pressure

History of Dental Treatment? YES NO

If YES, Describe ________________________________________________
Do you regularly check-up your teeth? YES NO
How often do you brush your teeth? ________________________________
How often do you floss your teeth? _________________________________
History of injury to your face,mouth or chin? YES NO
If YES, explain __________________________________________________
History of pain/ Tenderness in your jaw joint? YES NO
Do/Did you have any of the following habits?
Grinding Teeth Finger/Thumb Sucking Tongue Thrust
Mouth breather Speech Problems Chewing problems

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Extra Oral Examination
Facial Type: Mesocephalic Brachycephalic Dolichocephalic
Facial Symmetry: Symmetrical Asymmetrical
Upper dental midline: Deviated __________ mm to the ___________
Lower dental midline: Deviated __________ mm to the ___________
Facial Proportion:
Normal facial height Increased lower facial height Decreased lower facial height
Comment: _____________________________________________________________
Facial Profile:
Normal
Convex: slight moderate severe
Concave: slight moderate severe
Lips:
upper lip length: Normal Short
At rest: Normal strained Deficient lip seal
upper incisor show at rest: 0 mm 2mm 4mm 6mm

Neuromuscular Examination:

Tongue at rest: Normal Anterior Tongue Posture

Swallowing pattern: Normal Infantile (Tongue thrust)

Temporomandibular Examination:
Clicking: _________________________________
Pain: ____________________________________
Maximum opening: ___________mm
Deviation of mandible during closure: YES NO
If Yes, describe _________________________________________

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Intra Oral Examination:
Teeth Present:

Missing = M
Decayed= D
RCT=R
Filled= F

Molar classification: Right side Left side

CI CI
CII CII
CIII CIII
Canine Classification: Right side Left side
CI CI
CII CII
CIII CIII

Overbite: negative 0% 25% 50% 100%

Overjet: negative end-to-end Increased


Soft Tissue Assessment

Oral Hygiene: Good Fair Poor

Periodontal Assessment
Normal
Gingivitis Moderate Severe 


Crossbite Teeth involved ___________________________

Functional: YES NO

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Panoramic Radiograph Analysis:
Missing Teeth:____________________
Supernumerary Teeth: _____________
Impacted Teeth: __________________
Root resorption: __________________

Dental Cast Analysis:

Molar Rotation

Angle Classification CI CII CIII

________________________________________

Overbite

Overjet

Midlines

Arch Shape: Upper Lower

Ovoid
Tapered
Squared

Curve of Spee: Flat Moderate Exaggerated Reversed

Arch length analysis:

R 6 5 4 3 2 1 1 2 3 4 5 6 L

Space available: Maxilla _____ Mandible ______

Space required: Maxilla _____ Mandible ______
Space discrepancy: Maxilla _____ Mandible ______

Bolton analysis: ___________________________________________

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Cephalometric Analysis:

Skeletal
Dentoalveolar
Measurement Value Normal
Measurement Value Normal
SNA 82
U1 to L1 127
SNB 79
L1 to Mand Pl 95
ANB 3
U1 to Frank Pl 112
Facial Angle 87
U! to A-Pg(mm) 4
Angle of Convexity 4

Genial Angle 124

Cranial Base Angle 132

Soft Tissue
SN to Mand. Pl 32
Measurement Value Normal
Frank to Mand. Pl 23
H-angle 10
Y-axis to Frank. Pl 61
U-L-S -6
(S-Go)(N-Me)% 66
L-L 1
(ANS-Me)(N-Me)% 57
L-L-S -5
AB to Occ Pl (Wits -1
appraisal) Z-angle 71

Diagnosis:

3D-3T A-P plane Transverse plane Vertical plane

Skeletal

Dental

Soft Tissue

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Problem List:
_________________________________________________________________________
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_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Treatment Objectives:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

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Treatment Plan:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Sequence of Treatment:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
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_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Date: ____________ Student’s Name: ______________________________

Instructor’s Name: ____________________________

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Follow up Chart:

Date Wire Treatment

Next Visit

Next Visit

Next Visit

Next Visit

Next Visit

Next Visit

Next Visit

Next Visit

Next Visit

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