Early Orthodontic Assessment Form
Please complete this form to help us understand your child's orthodontic needs for an initial evaluation.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian Name
*
First Name
Last Name
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Has the child visited a dentist before?
*
Yes
No
Does the child have any of the following habits?
Thumb sucking
Mouth breathing
Teeth grinding
Nail biting
None of the above
Does the child have any medical conditions or allergies?
Current Orthodontic Concerns
*
Please rate the following orthodontic features
Rows
Not Present
Mild
Moderate
Severe
Crowding
1
2
3
4
Spacing
5
6
7
8
Overbite
9
10
11
12
Underbite
13
14
15
16
Crossbite
17
18
19
20
Open bite
21
22
23
24
Overall Oral Hygiene
1
2
3
4
5
Submit Assessment
Should be Empty: