Patient Information: Date
Patient Information: Date
Patient Information: 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?
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Have visited an orthodontist before? YES NO
If YES, for what reason? ________________________________________
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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:
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
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Panoramic Radiograph Analysis:
Missing Teeth:____________________
Supernumerary Teeth: _____________
Impacted Teeth: __________________
Root resorption: __________________
Molar Rotation
Overbite
Overjet
Midlines
R 6 5 4 3 2 1 1 2 3 4 5 6 L
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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
Diagnosis:
Skeletal
Dental
Soft Tissue
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Problem List:
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Treatment Objectives:
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Treatment Plan:
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Sequence of Treatment:
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Follow up Chart:
Next Visit
Next Visit
Next Visit
Next Visit
Next Visit
Next Visit
Next Visit
Next Visit
Next Visit
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