CCO Patient Diagnostic Sheet

Patient: __________________

Age: ______

Date: ________________
Chart: ________________

Referring Doctor: __________________

CC: __________________________________________________________________
Goals for Treatment: _____________________________________________________
Obstacles to Ideal Treatment: _______________________________________________
History of Concerns: _____________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Dental Data
Lower Archform

Normal

Spacing/Crowding

None

Upper Archform

Constricted

Mild

Moderate

Normal

Spacing/Crowding

None

Overbite
Overjet

Moderate

Severe

Severe

Shallow Open Deep

Ideal Mild Moderate Severe

Crossbite

Palpation (1-10)

Constricted

Mild

Ideal

Muscular TMJ Data

Negative

None Unilateral Bilateral Anterior Skeletal

Molar Class

1 II div. I

Wear Facets

II div. II

None

II sub R

II sub L III

Anterior Posterior

Excursion Right

Canine

Posterior GF

Anterior GF

NW Interferences

Excurstion Left

Canine

Posterior GF

Anterior GF

NW Interferences

Protrusive

Anterior Guidance

Balancing Interferences

Periodontal Data
Frenum
Biotype
Recession

Max Labial

Mand Labial

Normal
None

Yes

No

Temporalis
Masseter
Submandibular
Pterygoid
Occipital
SCM
Trapezius
Intracapsular
Resistance

Buccal

Thick

Localized: _________

Left

Clinical TMJ Data

Lingual

Thin

Right

Generalized

Right
Opening Click
Closing Click

Absent

Present

Crepitation

Visible Plaque

Absent

Present

Deviation

mm

Fremitus

Absent

Present

Max Opening

mm

Functional Shift

mm

Occlusal Trauma

None

Anterior

Posterior

Left

mm

R L A

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Transverse Diagnosis

Airway Data
CBCT

Skeletal

Snoring

CAC

Maxilla

Brux / Clench

AM Headache

Measured

Dental

Ideal

MGJ-MGJ

Mandible

FA-FA

Difference

CF-CF

Ideal

P-P
FA-FA

Tires Easily
Required

Asthma/Allergies

Space Requirement

Tonsils
Apnea

Crowding/Spacing
Maxillary Expansion

Radiographic TMJ Data

Right

Mandible

Incisor Inclination (X2)

mm2

Cross Section

Maxilla

Dental Expansion

Left

Curve of Spee

Past Remodeling

Tooth/Size Discrepancy

Altered Joint Space

Unresolved Space Requirement

Extraction

Subcortical Cyst

Distalization/Mesialization (X2)

Erosion

IPR

Edema

Final Space Requirement

Vertical Diagnosis (CR)

Sagittal Diagnosis (CR)

Skeletal

I / II / III

Skeletal

Open Normal Deep

Dental

I / II / III

Dental

Open Normal Deep

Maxilla

Maxilla

Mandible

Mandible

Overjet

mm

Overbite

Orthodontic Plan
Anchorage:

Min

Mod

Max

Maxilla:

Anchorage:

Min

Mod

Max

Mandible:

Patient: ___________________________

mm

Archform
Template
Mandible

Custom

Maxilla

Custom

Retention Strategy

Restorative Plan

Treatment Alerts

Surgical Plan

Periodontal Plan

Other Disciplines

Chart: ________________

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