Reference No. *0 / 7Upload file *Choose FileNo file chosenDelete uploaded fileUpload Patient's Assessment PhotoUpload file *Choose FileNo file chosenDelete uploaded fileUpload Patient's Assessment PhotoUpload file *Choose FileNo file chosenDelete uploaded fileUpload Patient's Assessment PhotoUpload fileChoose FileNo file chosenDelete uploaded fileUpload Patient's Assessment PhotoUpload fileChoose FileNo file chosenDelete uploaded fileUpload Patient's Assessment PhotoUpload fileChoose FileNo file chosenDelete uploaded fileUpload Patient's Assessment PhotoUpload fileChoose FileNo file chosenDelete uploaded fileUpload Patient's Assessment PhotoUpload fileChoose FileNo file chosenDelete uploaded fileUpload Patient's Assessment PhotoGeneral informationDateDoctor's Name *Patient's Name *Patient's DOB *Patient's Gender *MaleFemaleCurrent ConditionUpper MidlineLower Midlineshifted rightshifted rightshifted leftshifted leftCanine relationshipMolar relationshipright: classright: classleft: classleft: classInstructionsTreat archesupperlowerUpper midlinemaintainimproveidealizeLower midlinemaintainimproveidealizeOverjetmaintainimproveidealizeOverbitemaintainimproveidealizeArch formmaintainimproveidealizeCanine relationshipmaintainimproveidealizemolar relationshipmaintainimproveidealizePosterior CrossbitemaintainimproveidealizeIPRyesnoonly if neededAttachmentsyesnoonly if neededProclineyesnoonly if neededExpandyesnoonly if neededDistanlizeyesnoonly if neededAvoid attachments on these teeth (facial restoration, etc.)01020304050607083231302928272625RIGHT09101112131415162423222120191817LEFTDo not move these teeth (bridges, ankylosed teeth, etc.)01020304050607083231302928272625RIGHT09101112131415162423222120191817LEFTLeave these spaces open01020304050607083231302928272625RIGHT09101112131415162423222120191817LEFTI will extract these teeth before treatment01020304050607083231302928272625RIGHT09101112131415162423222120191817LEFTDoctor's Remarks *Submit
