Please enable JavaScript in your browser to complete this form.Patient's initials *Patient identifiers are limited on this form so patient privacy is maintained.DOBChief concernPresent at examMedical historyNilNADSignificant (additional information)GrowthJuvenilePre-pubertalPubertalPost-pubertalAdultAirwayOronasal breathingMouth breatherSigns of upper airway resistanceRadiographic signs of airway narrowingSTOP-BANG ≥3FacialBrachyfacialMesofacialDolichofacialConvex profileStraight profileConcave profileGenerally symmetricAsymmetricLipsCompetentIncompetentUndeterminedNormal verticalShortLongNormal APProtrusive APRetrusive APSkeletalClass IClass IIClass IIIMaxilla normal APMaxilla prognathic APMaxilla retrusive APMandible normal APMandible retrusive APMandible prognathic APNormodivergentLow angleHigh angleNormal maxilla verticalVertical maxillary excessVertical maxillary deficiencyGenerally symmetricAsymmetric MandibleAsymmetric MaxillaSmileConsonant smile arcFlat smile arcNarrow smileNormal Mx incisor display at restIncreased Mx incisor display at restDecreased Mx incisor display at restNormal gingival display (≺2mm) on smileIncreased gingival display (>2mm) on smileDecreased gingival display (≺0mm)Normal Mx incisor AP positionProtrusive Mx incisor AP positionRetrusive Mx incisor AP positionMidlinesFirstLastOral HealthSatisfactoryUnsatisfactoryCariesGingivitisPeriodontitisRestorative issuesOther pathologies (additional information)Gingiva & soft tissuesAverage gingival phenotypeThin gingival phenotypeThick gingival phenotypeRecession presentObstructive frenumHigh risk frenumDentitionPrimaryEarly MixedMixedLate MixedPermanentDental anomaliesEarly loss of deciduous teethOver-retained deciduous teethMissing teeth (hypodontia)Supernumerary teethPeg lateral (dimunitive)Microdontia/HypoplasiaMacrodontia/HyperplasiaFractured teethPoor prognosis teethAsymmetric eruptionEctopic teethImpacted teethIntra-occlusion/ankylosed teethSupra-eruptionOther (additional info)IncisorsClass IClass II div 1Class II div 2Class II indefiniteClass IIIPseudo Class IIIBimaxillary protrusiveBimaxillary retrusiveNormal angulationAnterior open biteAnterior deep biteTraumatic deep biteIncisor overjet (mm)Incisor overbite (%)RHS canine relationshipChoose an optionClass I canine1/4 Class II canine1/2 Class II canine3/4 Class II canineFull Class II canine1/4 Class III canine1/2 Class III canine3/4 Class III canineFull Class III canineRHS molar relationshipChoose an optionClass I molar1/4 Class II molar1/2 Class II molar3/4 Class II molarFull Class II molar1/4 Class III molar1/2 Class III molar3/4 Class III molarFull Class III molarLHS canine relationshipChoose an optionClass I canine1/4 Class II canine1/2 Class II canine3/4 Class II canineFull Class II canine1/4 Class III canine1/2 Class III canine3/4 Class III canineFull Class III canineLHS molar relationshipChoose an optionClass I molar1/4 Class II molar1/2 Class II molar3/4 Class II molarFull Class II molar1/4 Class III molar1/2 Class III molar3/4 Class III molarFull Class III molarTransverseNormalBilateral posterior crossbiteUnilateral posterior crossbiteFunctional shiftScissor biteMaxilla constrictedMandible constrictedMaxillary archNormalSymmetricAsymmetricMild crowding (≺4mm)Moderate crowding (4-8mm)Severe crowding (>8mm)Mild spacingModerate spacingSevere spacingNormal curve of SpeeDeep curve of SpeeReverse curve of SpeeMandibular archNormalSymmetricAsymmetricMild crowding (≺4mm)Moderate crowding (4-8mm)Severe crowding (>8mm)Mild spacingModerate spacingSevere spacingNormal curve of SpeeDeep curve of SpeeReverse curve of SpeeFunctionalCanine functionGroup functionInterference & shiftHabit-induced malocclusionTMDBruxismNormal swallowingAbnormal swallowingLispOther (additional information)Additional informationOrthodontist/Dentist name *FirstLastOrthodontist/Dentist email *Submit
