CLEARPATH ORTHODONTICS PVT LTD

DIAGNOSIS AND TREATMENT FORM

1. General Information
Doctor's Name: Email:
Shipping Address:
State: Country: Contact Number:
Patient's Name: Age: Gender:

2. Primary concern of the patient

3. Patient Diagnostic Information 4. Treatment Planning

Dentition Mixed ⃝ Permanent ⃝ Product Type CP-A ⃝ CP-B ⃝ CP-S ⃝
Treatment Indicated Both Upper ⃝ Lower ⃝ Gain Space Proclination ⃝ IPR ⃝ Expansion ⃝
Limited 8,7,6,5,4,3,2,1 1,2,3,4,5,6,7,8 (Please specify your preference by writing 1,2 & 3 in the circles above)
8,7,6,5,4,3,2,1 1,2,3,4,5,6,7,8

Treatment Deferred 8,7,6,5,4,3,2,1 1,2,3,4,5,6,7,8 Space Closure

8,7,6,5,4,3,2,1 1,2,3,4,5,6,7,8 UPPER Complete ⃝ Leave Space ⃝
Midline LOWER Complete ⃝ Leave Space ⃝
Centered Upper ⃝ Lower ⃝
(Complete space closure may require IPR. Default space will be left distal
to laterals)
Shifted UPPER R ⃝ L ⃝ LOWER R ⃝ L ⃝

Arch Width

Permanent Canine Relationship Upper arch Maintain ⃝ Expand ⃝ Constrict ⃝

Class I R ⃝ L ⃝ Class II R ⃝ L ⃝ Class III R ⃝ L ⃝ Lower arch Maintain ⃝ Expand ⃝ Constrict ⃝
Permanent Molar Relationship Midline
Class I R ⃝ L ⃝ Class II R ⃝ L ⃝ Class III R ⃝ L ⃝ Maintain ⃝

Incisor Relationship Correct ⃝ Move Upper____mm Move Lower____mm

Overjet______mm Overbite______mm

Tooth Size Discrepancy Permanent Canine Occlusion Goal

Lower Jaw Excess ⃝ Deficient ⃝ Class I R ⃝ L ⃝ Class II R ⃝ L ⃝ Class III R ⃝ L ⃝
Upper Jaw Excess ⃝ Deficient ⃝ Permanent Molar Occlusion Goal
Cross bite 8,7,6,5,4,3,2,1 1,2,3,4,5,6,7,8 Class I R ⃝ L ⃝ Class II R ⃝ L ⃝ Class III R ⃝ L ⃝
8,7,6,5,4,3,2,1 1,2,3,4,5,6,7,8

Cephalometric Values (Optional) Required Overjet____mm Required Overbite_____mm

Sketetal Analysis Dental Analysis Tooth Size Discrepancy IPR ⃝ Leave Space ⃝
SNA________ UI-SN_________ (Default space will be left distal to laterals, plz specify if otherwise)
SNB_______ UI-Palat_______
ANB______ IMPA__________ Correct Cross 8,7,6,5,4,3,2,1 1,2,3,4,5,6,7,8
WITTS value______mm Bite 8,7,6,5,4,3,2,1 1,2,3,4,5,6,7,8
SN_Pg______ Soft Tissue Analysis
SN_Mand______ Nasolabial______ Recommended 8,7,6,5,4,3,2,1 1,2,3,4,5,6,7,8
MMA_____ U-Lip to E-Line______mm Extraction 8,7,6,5,4,3,2,1 1,2,3,4,5,6,7,8
Y-Axis______ L-Lip to E-Line______mm

5. Special Instructions

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