Patient Information

Patient Name Responsible Party Self Mother Father Parent Guardian Other Chief Concern

Doctor / Referral Copy

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Clinical Findings

Skeletal Relationship Class I Class II Class III Asymmetry Growth evaluation needed Dental Relationship Class I Class II Class III Subdivision Mixed dentition Maxillary Crowding None Mild Moderate Severe Mandibular Crowding None Mild Moderate Severe Maxillary Spacing None Mild Moderate Severe Mandibular Spacing None Mild Moderate Severe Overjet Normal Increased Severe Negative overjet / anterior crossbite Overbite Normal Deep bite Open bite Edge-to-edge Anterior Crossbite None Single tooth Multiple teeth Complete anterior crossbite Posterior Crossbite None Unilateral Bilateral Scissor bite tendency Midline Coincident Upper midline deviation Lower midline deviation Both upper and lower deviation Habits None reported Thumb/finger habit Tongue thrust Low tongue posture Bruxism / grinding Airway / Mouth Breathing No major concerns reported Mouth breathing Snoring reported ENT evaluation recommended Airway evaluation recommended TMJ Symptoms No symptoms reported Clicking Pain Limited opening History of locking/dislocation Oral Hygiene Good Fair Poor Needs improvement before treatment

Doctor Assessment

Diagnosis / Main Findings Treatment Recommendation Observation / Growth Monitoring Phase I Orthodontic Treatment Full Braces Invisalign / Clear Aligners Limited Orthodontic Treatment Retainers Only Referral / Further Evaluation Needed Estimated Treatment Length Observation 6-9 Months 12 Months 18 Months 18-24 Months 24 Months 24+ Months Extractions No extractions anticipated Extractions recommended Possible extractions depending on response Evaluate extractions after 6-9 months Extraction decision pending records/imaging Surgical Need No surgery anticipated Surgical orthodontic evaluation recommended Possible surgery depending on growth/response Jaw surgery likely needed for ideal correction Oral surgery referral needed Appliances / Auxiliaries Next Steps Doctor / Notes

Patient / Parent Signature

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