Date_____________ Patient’s name Mailing Address___________________________

Home phone___________________ Work phone Reference code

Birthdate_______________ Marital Status: Occupation__________

Whom may we thank for referring you to our office?________________________________________________

MEDICAL HISTORY
any medication? allergic to any medication? major illness? any operations? serious accident?_smoked or
chewed tobacco? physician in the last 12 months? Why? pregnant?_______________________________

DENTAL HISTORY

PATIENT/PARENT CONCERNS RE: TX

_______________________________________________________________________

Assessment
Extra-oral
Skeletal classification Class I Class II Class III
FM angle High Average Low
Transverse asymmetry? Yes No
TMJ symptoms / click? Yes No
Lips: Competent? Yes No
Digit sucking habit? Yes No
Intra-oral
Teeth present: _____________/______________ Teeth absent: _________/_________
/ /
Oral hygiene: Good Average Poor
Erosion / decalcification evident? Yes No
Caries evident: ____________/_______________
/
Teeth of doubtful prognosis: ___________/____________
/
Occlusion
Incisor relationship: Class I Class II/1 Class II/2 Class III
Overjet ……….mm Edge to edge
Overbite
Anterior open bite……....mm
Centre lines _______/________ (show shift by arrows)
/
Anterior cross-bites: ______/________
/
Buccal occlusion: Right: Class I Class II: ¼ unit ½ unit ¾ unit full unit Class III
Left: Class I Class II: ¼ unit ½ unit ¾ unit full unit Class III
Posterior cross-bites: ______/______
/
Associated mandibular displacement (mm): Right……..Left…… Anterior……….
Radiographs:
Teeth absent: ________/_________ Pathology evident: Yes No Details …………………………
/
Cephalometric analysis: SNA ……….° SNB…..…..° MMPA ……..° UI- MxP……..…° LI-MdP ……
°LI-APo ……….mm

APPLIANCES
Fixed appliance:
Type_______________ Manufacturer _____________ Type of bracket: � metal or � non-metal
Variations__________
Date bands and/or brackets placed: Max_______ Mand _______ Bonding Agent _______ Cementing
Agent _________

Extraoral appliance:
Type________________ and dates initiated______________________ Hours requested
____________________________
Case/Patient number______________________
Treatment Relief of crowding Maxillary arch-expansion
Aims of Treatment:
Alignment Levelling Arch-co-ordination Correction of incisor relationship

Space closure occlusion: antero-posteriorly

laterally
Correction of buccal segment

Extractions:
________/__________
/

Appliances Provided: Type of Date fitted Date withdrawn / removed

appliance
Upper fixed appliance
Lower fixed appliance
Removable retainers Upper:
Lower:
Fixed retainers Upper:
Lower:

BENEFITS

Benefits of Orthodontics: Aesthetics, Health, and Function. Orthodontics is a service that provides an
improvement in the appearance of the teeth, in the general function of the teeth, and in general dental
health. Teeth, gums, and jaws are an intricate body part and can fail to respond to treatment. If good oral
hygiene is not practiced, tooth decay and enlarged gums can result. Joint discomfort and root shortening
are observed in a small percentage of cases. Teeth change throughout our lifetime and there can be some
movement of teeth and some change after treatment. I have read and understand this paragraph. I also
understand that my diagnostic records and my name may be used for educational and promotional
purposes. I have truthfully answered all the above questions and agree to inform this office of any changes
in my medical or dental history. In addition, I authorize Dr. ____________________ to perform a
complete orthodontic evaluation.

Signature:_____________________________________Date:_________________