Orthodontic Aligner Treatment Monitoring Form
Please complete this form to help your orthodontist monitor your aligner treatment progress.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Current Aligner Number
*
How many hours per day are you wearing your aligners?
*
Less than 18 hours
18-20 hours
20-22 hours
More than 22 hours
Have you experienced any discomfort or pain since your last check-in?
*
No discomfort
Mild discomfort
Moderate pain
Severe pain
Have you noticed any cracks or damage to your aligners?
*
No damage
Minor cracks
Significant damage
How would you rate your oral hygiene during aligner use?
*
Excellent
Good
Fair
Needs improvement
Have you missed any days of aligner wear since your last check-in?
*
No days missed
1-2 days missed
3 or more days missed
Any additional comments or concerns?
Submit
Should be Empty: