Stage 1 Case Wizard

Patient Name*

Patient Email*

Patient ID*

Age*

Ethnicity*

Birthday *

Gender*

Date *

Reason for Office Visit for Dental or Sleep Issues?*

Molars

Current Condition Yes No

Does the patient have 2nd decidous molars present in the oral cavity?*

Does the patient have 1st permanent molars present in the oral cavity (6 year molars)?*

Does the patient have 2nd permanent molars present in the oral cavity?*

Overbite *

mm (If no overbite present, put value as 0)

Overjet*

Open Bite*

Current Condition Yes No

Class III*

Psuedo* Psuedo-Class III malocclusion is characterized by the presence of an anterior crossbite due to forward functional displacement of the mandible; in most cases, the maxillary incisors present some degree of retroclination, and the mandibular incisors are proclined.

Skeleton* This malocclusion has been characterized by skeletal, functional and dental discrepancies, which may or may not be associated with each other. In the facial evaluation, mandibular prognathism, maxillary retrognathism or both can be observed, characterizing a skeletal Class III malocclusion.

End To End*

Crossbites

Current Condition Yes No

Crossbites*

Clinical Observations

Current Condition Yes No

Tongue-tied (Ankyloglossia)*

Are tonsils almost touching? (Evaluate in a horizontal position)*

Grade 0* (Grade 0: Tonsils absent)

Grade 1-2* (1: Hidden behind tonsillar pillar, 2: Extended to pillars)

Grade 3-4* (3: Visible beyond pillar, 4: Enlarged to midline)

Is there Adenoid Swelling? (Ceph Evaluation)* No Ceph Available

Has interrupted snoring stopped for 3 or more seconds?*

Has stoppage of breathing for more than 2 times an hour?*

Has difficulty with nasal breathing?*

Can patient breathe through the nose for 15 seconds?*

Gummy Smile

Gummy Smile *

Greater or equal to 2mm is abnormal size*

Have centrals already erupted? *

Height

Height* Father* Mother*

Biological Parents *

Yes No

Non-Biological Parents * Yes No

Other

Older Siblings Sister Age

Brother Age

Profile

Current Condition Yes No

Mandible Retrusive*

Maxilla Retrusive*

Misc. Questions

Yes No

Breast Fed - To What Age?*

Bottle Fed - How Long?*

Pacifier Use - How Long?*

Speech Lessons - How Long?*

Rest Jaw on Fist - Frequent?*