Form

Orthodontic Evaluation

Patient Name:

Age:

Date

Reason for Orthodontic Consult:

Head and Neck/ Oral Cancer Evaluation:

TMJ:

Past History of Orthodontic

Injury to Head, Mouth, or Neck:

Habits:

Skeletal

Skeletal

Dental Midline

Face Type

Profiles

Right Molar Classification:

Left Molar Classification:

Right Canine Classification:

Left Canine Classification:

Dental Arragements/ Shape:

Overbite: %

Overjet: mm

Underbite: mm

Openbite: mm

Diastema:

Cross-Bite:

Spacing:

Impacted:

Bolton Discrepancy:

Blocked:

Rotated:

Peg Lateral:

Upper Crowding:

Lower Crowding:

Wisdom Teeth:

Periodontal status:

Caries/ Decalcifications:

Frenum:

Missing teeth:

Meisal Drift:

Supraerupted teeth:

X-rays findings:

Treatment Recommendations/Options:

Ext:

Appliances:

Missing teeth spaces:

Ortho/ Restorative:

Limiting Factors:

Hygiene Recommendations:

Treatment Duration:

Types of Retention:

Comments/ Other Findings

Examined By

First Name

Last Name

Date Of Birth

Patient/Legal Guardian Signature

Date