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NAMA PASIEN: . Usia: TH P/L

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NAMA PASIEN : ……………………………………………………………………………………………….

USIA : th P/L
Riwayat penyakit: tonsilitis, asma, alergi, epilepsy, kelainan darah dll
Kebiasaan buruk:
Lip/Nail/Pencil Bitting, Thumb Sucking, Tongue thrusting, Tongue posture, mouth breating, Snooring,
Bruxism

Profil Wajah Lateral

Cekung/Datar/Cembung
Analisis Jaringan Lunak:
Furkasi : ………………………………………………………………………………………………
OH

Dental Analisis

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