Tratamiento Ortodoncia

Patient:_________________________
Doctor:__________________
Age:___________________
Date of Birth:_____________
___________________

Evaluation date:______________

Medical History: ____Healthy

Facial Form:
_____Dofichofacial
Max.____Retrognathic
_____Mesofacial
Max____Retrognathic
_____Brachyfacial
_____Asymmetries_____________

____Prognatic
_____Prognatic

Habits:
___None
_____Thumb/finger
______Bruxing___Clenching
Others:___________________________________
Occlusion:
Profile

Molars

Cuspids

Overbite

Overjet

Crossbites

Midline Off

Straight

Class I

Class I

Open

Normal

None

Max

Convex

Class II

Class II

Normal

Mod

Post

Mand.

Concave

Class III

Class III

Closed

Severe

Ant.

Right

Mod
Severe

Crowding
Max

Mand

Mod

Mod

Severe

Severe

Spacing

Spacing

Left

Missing/
impacted
teeth

Tooth # for banding___________

Extractions: _____________