Free template
Orthodontic assessment note template
For a new orthodontic assessment or referral: facial and occlusal analysis, the dental arch and problem list, and the treatment options and plan discussed. Built for a first orthodontic consultation rather than a routine adjustment visit.
PRESENTING COMPLAINT
Reason for Visit:
Assisted by:
MEDICAL HISTORY
Medical History:
Allergies:
Medications:
PMS Updated:
EXTRAORAL EXAMINATION
Mouth Opening:
Toothwear:
Skeletal Class:
Competent Lips:
Smile Arc:
Buccal Corridors:
OCCLUSION
Incisor Relationship:
Molar Relationship (Right):
Severity (Right):
Molar Relationship (Left):
Severity (Left):
FACIAL AND DENTAL ANALYSIS
Lower Facial Height:
Mandibular Plane Angle:
Transverse Relationship:
DENTAL ARCH ANALYSIS
Crowding:
Spacing:
Overjet:
Overbite:
Centrelines Coincident:
Teeth in Crossbite:
Displacement:
Open Bite:
Arch Form:
Smile Line:
PROBLEM LIST
Problem List:
Problem List Explained:
TREATMENT OPTIONS
Orthodontic Plan:
Retention Plan:
OPTIONS & ALTERNATIVES
Options Discussed:
Estimate Discussed:
ADDITIONAL DETAILS
Declined Treatments:
Aware Not An Orthodontic Specialist:
Offered Specialist Referral:
Discussed Process (Aligners, Attachments, IPR, Retention):
Discussed Compromised vs Comprehensive:
Patient's Preference:
Photos Today:
PLAN
Next Visit:
GDC standard 4.1 expects a patient's clinical record to be made as the appointment happens, and to be accurate and complete.
How Assist helps
Assist fills this in for you.
Assist records the appointment and drafts a note in this structure for the dentist to review and sign off. It writes up what was said in the room, and you check every line before it goes in the record.
28 days free. No card required.
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