Orthodontic Overjet Assessment Form
Orthodontic Overjet Assessment Form for evaluating a patient's overjet in an orthodontic context.
Patient Initials
*
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Measured Overjet (in millimeters)
*
Overjet Severity
*
Normal
1
2
3
4
Severe
5
1 is Normal, 5 is Severe
Presence of Habits Affecting Overjet
*
None
Thumb Sucking
Tongue Thrusting
Other
Overjet Impact on Function
*
Rows
Not at all
Mild
Moderate
Severe
Speech
1
2
3
4
Chewing
5
6
7
8
Aesthetics
9
10
11
12
Associated Occlusal Findings
*
Open Bite
Deep Bite
Crossbite
None
Patient Age Group
*
Please Select
Under 10
10-14
15-18
Over 18
Assessor Name
*
Additional Comments
Submit Assessment
Should be Empty: